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FEMALES 



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AXD THZIR 



DISEASES 



A SERIES OF 



LETTERS TO HIS CLASS, 



BY 



CHARLES D. MEIGS, M.D., 

Professor of Midwifery, and the Diseases of Women and Children, in the Jefferson Medical 

College at Philadelphia; Member of the American Medical Association; of the 

American Philosophical Society, and one of the Council; Fellow of the 

College of Physicians of Philadelphia; one of the Physicians to 

the Lying-in Department of the Pennsylvania Hospital ; 

&c. &c. 








PHILADELPHIA: 

LEA AND BL AN CHARD 

1848. 



Entered according to the Act of Congress, in the year 1847, by 

LEA AND BLANCHARD, 

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



PHILADELPHIA \ 
T. K. AXD P. G. C0LLIXS, PRINTERS. 



TO THE 

STUDENTS OF MY CLASS, 

IX THE 

SESSION OF 1846-7, 

THIS VOLUME 

IS RESPECTFULLY AND AFFECTIONATELY 

JDebtxateir, 

BT 

THEIR GRATEFUL FRIEND, 

THE AUTHOR. 



AN INTRODUCTORY LETTER TO A FRIEND. 

Dear Sir : 

I send you a new Medical book, which I beg you to accept as a 
testimonial of my respect and affection. I have not dedicated it 
to you, because it belongs to the Gentlemen to whom I addressed 
the Letters of which the volume consists. I shall be obliged to 
you if you will look at it, and tell me whether you think I have 
committed an unpardonable breach of the forms of our Science, 
by writing with such a freedom and abandon as you shall here 
find. 

Dr. Forbes, in his last article, in the British and Foreign 
Medical Review, tells us it is a lamentable truth that the eminent 
practitioners of England neither read nor buy medical books; and 
I fear a chief reason of it is to be found in the dulness and jargon 
which characterize so many medical writings. I am sure that, 
excluding such as treat of the Physiology of Man, many are very 
tiresome and disgusting; for, the Doctors seem not to have heeded 
the lines of Horace, where he says : 

"Ornne tulit punctum qui miscuit utile dulci, 
Lectorem delectando pariterque monendo." 

I have endeavored, according to my poor ability, to tell the 
truth about our Science and Art, and in doing so, to avoid the 
dulness — and I thought the honestest way for a man to speak is, 
to speak what he thinks, in his own tone and manner, and not to 
come before the public under a false disguise. The young gen- 
tlemen who composed my Class, were accustomed, all winter, to 
hear me say just whatever the occasion prompted me to say to 
them, without any reservation of mine, from distrust of them ; for 
I went into the Lecture room with my heart in my hand ; and it 
is in the same fashion that I have sent them these Letters. In- 
deed, when I promised to write for them, I engaged to adopt the 

1* 



VI INTRODUCTORY LETTER TO A FRIEND. 

most familiar style, saying, " I will write in the same language I 
should address to any one of you, whom I might be instructing, 
in my library here at home." 

You will see that I have kept my promise. Whether such a 
mode of writing may prove agreeable to the brethren, so as to 
meet their approbation, remains to be seen. If I have failed, let us 
hope that some one else will try some other method to get rid of 
our medical dulness, and our time-honored clergyableness; for, 
to judge of the medical student of the present day, by comparing 
my own student life with his, I cannot but think he must still find 
the books as tedious and uninteresting as they used to be when 
we were young men like them. 

As to the doctrine and the precept of these Letters, I should 
suppose, I have a right, at this stage of my life, to be heard upon 
them — and having felt it an occasion of self-reproach, that I 
could never find time, in the winter curriculum, to fulfil my duties 
as Lecturer on Diseases of Females and Children, I have taken 
occasion to speak to my Class through the press. In doing so, I 
cannot but stand before the public. 

Flaccus says, " Scribendi rede, sapere est etprincipium etfons." 
You will be able to judge whether I have said that which is naught 
as to the diseases treated of herein. Certainly, I have had much 
opportunity to see the things spoken of, and if the book turns out 
useless or disagreeable, mine is the fault. You, who have seen 
so much, may be my competent and dispassionate judge. 

Let me tell you, though, my dear Hodge, that the whole of these 
660 pages have been begun and finished since the month of May 
last. They have none of the nonum prematur in annum merit, 
therefore — and I wish you to understand, that, I have been obliged 
to do the whole of the work, in addition to my diurno-nocturnal 
task of visiting the sick. I cannot, under these circumstances, 
claim for it the same consideration as might be due to essays 
carefully revised and finished; and I have a just right to make this 
apology. But, shall people, who desire to make a contribution 
to the art that has absorbed their whole existence, refrain from 
doing so from a fear of offending in the matter of their manner? 
Would that be American-like? And shall they go out of the 
world making no sign? — Beaufort was asked but to hold up his 
hand, but "he died and made no sign." 

I wish you would make a sign for us ; we all wish so. 



INTRODUCTORY LETTER TO A FRIEND. Vll 

I have made this apology to you, my dear Hodge, because I 
look upon you as a chief representative of Medicine, on this topic, 
in the United States: and, as I desired to say a few words to the 
brethren, in addition to all I have said in these Letters to my 
Students, I trust that in saying these things to you, in whom 
they have confidence, I am, quoad hoc, absolved as to apologies. 
As to my personal feelings towards you — did we not sit on the 
same benches at the lectures ? — and have we not interchangeably 
assisted us with counsel and with dexterity, in our vocation 
these thirty years? — What more! 

I pray God to prosper you long ; and to allow the City, and the 
Country, to enjoy, for many years, the advantages of your skill, 
the honor of your well-earned reputation, and the benefit of your 
public instruction, as well as your private example as a minister 
of your philanthropic calling. Farewell, dear doctor, and believe 
me very faithfully 

Your affectionate friend, 

CHARLES D. MEIGS. 

To Hugh L. Hodge, M.D., 

Professor of Midwifery and Diseases of 

Women and Children, in the University of Pennsylvania. 



CONTENTS 



PAGE 

DEDICATION, iii 

LETTER TO A FRIEND, ...... v 

LETTER I. 
Motives for writing, - ..... 17 — is 

LETTER II. 

General remarks on conduct — Embarrassments of practice — Sir Thomas Browne's 
opinion of the practice of medicine, ..... 18 — 29 

LETTER III. 

Sex — The ovum — Vitellus — The corpus luteum, - 30 — 37 

LETTER IV. 
The female — Her distinctive characteristics, .... 37 — 52 

LETTER V. 

Sexual organs — Mons — Relaxed symphyses — Seton in pubal pains — Vulva — Labia 
pudendorum — (Edema labiorum, - 53 — 63 

LETTER VI. 

Wounds and laceration of the labia — Labial thrombus, - 64 — 68 

LETTER VII. 

Ruptured labium — Ruptured labium and perineum — Uncured laceration of peri- 
neum with procidentia uteri — Labial cysts — Warts of the vulva — Dr. Brainerd's 
letter to J. F. Meigs— Pruritus of the vulva — Cicatrices, - - 6S — 79 

LETTER VIII. 
NymphaB — Cohesion of the nymphee, ..... 79 — S3 

LETTER IX. 

Vagina — Its structure and relations — Absence of the vagina — Operation by Dr. 
Randolph for absence of vagina — Congenital narrowness of the vagina — Dilata- 
tion of the vagina as a cure — Imperforation or atresia — Cases — Cohesion of va- 
ginal walls after labor — Case of the same — Ulceration of the vagina — Vaginitis 
— Inversion of the vagina — Vaginal fistula — Vaginal rectocele — Vaginal entero- 
cele — Vaginal cystocelc — Double vagina, .... S3 — 112 



X CONTENTS. 

PAGE 

LETTER X. 

Cohesion of labia and nymphse — Ulcerated nymphse — Excision of nymphae, by 
Mauriceau, -------. 113 — H7 

LETTER XL 

Clitoris — Herraaphrodism — Free Martin — Nymphomania — Inversion of the blad- 
der — Mr. Crosse's case, ---... H8 — 126 

LETTER XII. 

Displacements of the womb — Prolapsus uteri — Lamotte's account of it — Prolap- 
sus, with abdominal neuralgia. — Case — Levators ani in prolapsus — Diagnosis — 
Carus' curve — Dr. J. H. Bennet — Causes of prolapsus — Pessaries — Gynsecio- 
rum of Spach — Simulative prolapsus — Miss Helen Blanque's case, and dialogue 
with her, --.-.--- 127—163 

LETTER XIII. 

Diagnostics of prolapsus — Bad training of girls — Quevenne's metallic iron — 
Powers of medicines — Dr. Cerise on neurosity, ... 163 — 169 

LETTER XIV. 

Pessaries — Mr. Joseph Warner and his instruments — Dr. Physick's pessary — 
Suffita — Sachet — Sponge — Cork — Caoutchouc — Whalebone-ring — Blundell's pes- 
sary, ........ 170—182 

LETTER XV. 

Prolapsus in the unmarried — Case — Immobility of the womb — Case — Cautions 
as to pessaries — Utero-abdominal supporters, ... 182 — 189 

LETTER XVI. 

Retroversion of the womb — Wood-cut of retroversion — Dr. Amussat's pamphlet — 
Wm. Hunter and Dr. Hall — Dialogue with a patient — Cases — 'Treatment — 
Chronic retroversion — Pregnancy as a cause of retroversion — Dr. Weir — Mr. 
Mayor's case — Instrument for the repositing of the womb, - 190 — 218 

LETTER XVII. 

Anteversion of the womb — Flexion of the womb, ... 219 — 226 

LETTER XVIII. 
Inversion of the womb — Mr. Crosse of Norwich, in England, - - 227 — 240 

LETTER XIX. 

Dr. Betton's case of inversion — Polypus of the womb — Dr. Safford Lee cited — 
Anne Ryder's case — Dialogue with a patient — A case of polypus — Adherent 
polypus, ......-- 241—259 

LETTER XX. 

Polypus — Hasty diagnostics — Nascent polypus, - - - 259 — 264 



CONTENTS. XI 

PAGE 

LETTER XXI. 
Fibrous tumors of the womb — M. Serres' Anatomie Transcendente quoted, 264 — 278 

LETTER XXII. 
Cancer of the womb, ------- 278—288 

LETTER XXIII. v 

Physometra— Tympanitis, .---.- 288—296 

LETTER XXIV. 

Hydrometra — Hydatids, - - - - - 296—299 

LETTER XXV. 

Ovarian disease — Ovariotomy — Dr. Lee's tabular results, - - 299 — 323 

LETTER XXVI. 

Diseases of the Fallopian tubes — Tubal pregnancy — Cases — Ovarian pregnancy — 
M. Pouchet's opinion, ...... 324 — 331 

LETTER XXVII. 
Puberty, ........ 331—374 

LETTER XXVIII. 

The menstrua — Periods of eruption — Climatic influences — Nature — Causes — 
Extract from Burdach — Germ-production in vegetables and in animals — Migra 
tion of animals, birds, and fishes, ----- 374 — 385 

LETTER XXIX. 

Periodicity of germ-production, or ovulation — Secretions — Prof. Huschke — Martin 
Barry and Gerber — Negrier, Gendrin, Lee, Bischoff, and Pouchet — M. Pouchet's 
Theorie Positive — Rapid evolutionof a Graafian cell, - - 385 — 392 

LETTER XXX. 

Corpus luteum — Author's opinion — Opinion of authors, as Henle, Carpenter, 
Huschke, Flourens, Velpeau, Jacquemier, Chailly, Bernhardt, Von Baer, Bischofi 
— Experiments: constitution, and uses of the corpus luteum, - 393 — 401 

LETTER XXXI. 

Menstrua — Brierre de Boismont's tables — Analyses of menstrual fluid — Rachel — 
Roussel, -.-.-.-- 401—415 

LETTER XXXII. 
Emmenagogues, ....... 410 — 4-: 3 

LETTER XXXIII. 
Menorrhagia, -------- 424—434 



Xll CONTENTS. 

PAGE 

LETTER XXXIV. 
Dysmenorrhoea, - .._... 434 — 443 

LETTER XXXV. 
Change of life, -------- 444 — 454 

LETTER XXXVI. 
Hysteria. .----... 455 — 471 

LETTER XXXVII. 

Disorders of pregnancy — Fecundation and conception — Early changes of the womb 
— Uterine intrusion — Ovum grows by vis insita — A ventre plat, enfant ily a — Sym- 
pathy with uterus in the mammary glands, the stomach, &c. — Missing the 
return — Quickening — Rational signs and sensible signs — Some of the signs, as 
diseases of pregnancy — Salivations and vomitings — Bruit de souffle uterin — 
Sounds of foetal heart — Dr. J. A. H. De Paul, of Paris, and his work on Auscul- 
tation — Early discoveries of foetal heart — Evory Kennedy and others — (Edema 
gravidarum — Constipation — Compression of the great vessels by womb — Dura- 
tion of gestation — Incipient phlebitis from varix, ... 472 — 500 

LETTER XXXVHI. 

Disorders of pregnancy continued — Cost of pregnancy to the blood-membrane — 
Anaemia — A case — Palpitation — Endocarditis — Dropsy of chest — Sprain of the 
symphyses — Dr. Moreau's case detailed, - - - - 501 — 519 

LETTER XXXIX. 

Abortion — Dr. Merriman's table of duration of pregnancy — Causes of abortion — 
Take care of the pregnancy ! — Hemorrhage — Prophylaxis, - - 519 — 548 

LETTER XL. 

Lying-in diseases — Fainting after delivery — Concealed hemorrhage — Turn out the 
clots — Binder and compress — Keep the head down — Ergot — Opium — After- 
pains — Rheumatismus uteri — Neuralgia of womb and abdomen — Lochia — Dr. 
Lee of London — Asdrubali on bandaging the accouchee< — Retention of urine — 
Medicines for the accouchee — Diet — Dies nondinse — Vaccination of pregnant 
women, ---.-_.- 548 — 575 

LETTER XLL 
Puerperal fever, ------- 576—624 

LETTER XLII. , 
Phlegmasia dolens, or crural phlebitis, .... 624 — 631 

LETTER XLIII. 
Puerperal convulsions, ------- 631 — 643 

LETTER XLIV. 
The female breast, ------- 643—661 



FEMALES: 



DISEASES AND REMEDIES 



LETTER I. 

MOTIVES FOR WRITING. 

Gentlemen: — When I took leave of you, at the close of the 
session of our Lectures on the last of February, I engaged to 
address to you a series of letters, in which I should endeavor 
to lay before you my views upon some of the disorders of females ; 
and you may remember, I on that occasion, requested each one 
of you to consider these letters as addressed to himself. I felt 
that I had not fully discharged the obligations of my professor- 
ship as relates to disquisitions upon the sexual maladies ; and 
explained to you that the time allowed for a course of lectures, 
a period of only four months, is too short to permit any one fully 
to describe the many diseases to which females are liable. 

I had taken advantage, it is true, of every open occasion to 
describe the phenomena and treatment of the disorders and acci- 
dents of the various structures which it was my province to 
demonstrate. Still there was much incumbent on me to say, 
which the shortness of your sojourn here would not allow me 
leisure to say. 

When I enjoyed the satisfaction of meeting you in the after- 
noons, I felt that my happiness was to be esteemed great, in the 
privilege of addressing so great a number of gentlemen, all pa- 
tiently and politely receiving the instruction I w r as able to con- 
vey upon very important points of a- business, which is related 
2 



18 GENERAL REMARKS ON CONDUCT. 

to some of the most delicate and hazardous periods of female 
existence; I need not repeat the assurances I gave at parting 
with you, that I was filled with painful emotions in bidding 
you farewell, for I could not be insensible to the goodness you 
had so steadily manifested towards me, or to the admirable con- 
duct of the whole class, which reflects the highest credit upon 
them, as demonstrative of their fine sense of what is due both to 
themselves and to their teachers, whom they distinguish and ele- 
vate by such consistent and admirable deportment. 

To address these letters to you now, seems to be a renewal of 
our late delightful intercourse, and should I be permitted in the 
course of them to assist you, and strengthen your hands in your 
great mission of usefulness and benevolence, I shall be thankful 
to Him by whose Providence I have been allowed these now 
many years, to observe and contemplate the affections of which 
I am about to treat. Farewell. C. D. M. 



LETTER II. 
GENERAL REMARKS ON CONDUCT. 

The relations between the sexes are of so delicate a character, 
that the duties of a medical practitioner are necessarily more 
difficult when he comes to take charge of a patient laboring under 
any one of the great host of female complaints, than where he is 
called upon to treat the more general disorders, such as fevers, 
inflammations, the exanthemata, &c. So great, indeed, is the 
embarrassment arising from fastidiousness on the part either of 
the female herself, or of the practitioner, or both, that, I am per- 
suaded, much of the ill success of treatment maybe justly traced 
thereto. 

It is to be confessed that a very general opinion exists, as to 
the difficulty of effectually curing many of the diseases of women ; 
and it is as mortifying as it is true, that we see the cases of these 
disorders going the whole round of the profession, in any vil- 
lage, town, or city, and falling, at last, into the hands of the 
quack; either ending in some surprising cure, or leading the 



EMBARRASSMENTS IN THE PRACTICE. 19 

victim, by gradual lapses of health and strength, down to the 
grave, the last refuge of the incurable, or rather the uncured : I 
say uncured, for it is a very clear and well known truth, that 
many of these cases are, in their beginning, of light or trifling 
importance — cases in which the constitution takes no part in 
affections of tissues or organs, which, when slightly modified by 
disease, may long continue to be so without provoking any dis- 
turbance as to the harmony of the other great organs : this for 
example, in the organs of the circulation, nutrition, respiration, 
and innervation. Yet, by neglecting such affections in their rise, 
on the one hand, or by imprudently treating them by violent and 
disturbing therapeutical or hygienical methods on the other, the 
whole constitution at length comes into sympathy with the de- 
ranged member of it; and the health, the usefulness, and so, the 
happiness or life of the mismanaged and misinformed female, are 
sacrificed. 

All these evils of medical practice spring not, in the main, 
from any want of competency in medicines, or in medical men ; 
but from the delicacy of the relations existing between the sexes ; 
and, in a good degree, from the want of information among the 
population in general, as to the import and meaning, and tend- 
ency of disorders, manifested by a certain train of symptoms. 

It is, perhaps, best, upon the whole, that this great degree of 
modesty should exist even to the extent of putting a bar to 
researches, without which no very clear and understandable no- 
tions can be obtained of the sexual disorders. I confess I am 
proud to say, that, in this country generally, certainly in many 
parts of it, there are women who prefer to suffer the extremity of 
danger and pain rather than waive those scruples of delicacy 
which prevent their maladies from being fully explored. I say 
it is an evidence of the dominion of a fine morality in our society ; 
but, nevertheless, it is true that a greater candor on the part of 
the patient, and a more resolute and careful inquiry on that of 
the practitioner, would scarcely fail to bring to light, in their 
early stages, the curable maladies, which, by faults on both sides, 
are now misunderstood, because concealed, and, consequently, 
mismanaged and incurable. In fact, what is it, in the human 
body, that can become disordered so secretly as to elude the ex- 
ploratory powers of a well educated medical man, who is allowed 
to make the necessary inquiries? 



20 EMBARRASSMENTS IN THE PRACTICE. 

It is an interesting question, as to what can be done to obviate 
the perpetuity of such evils — evils that have existed for ages. Is 
there any recourse by means of which the amount of suffering 
endured by women affected with peculiar complaints, may be 
greatly lessened? 

I am of opinion that the answer ought to be affirmative ; for I 
believe, that if a medical practitioner know how to obtain the 
entire confidence of the class of persons who habitually con- 
sult him; if he be endowed with a clear perceptive power, a 
sound judgment, a real probity, and a proper degree of intelli- 
gence, and a familiarity with the doctrines of a good medical 
school, he will, as far as to the extent of his particular sphere of 
action, be found capable of greatly lessening the evils of which com- 
plaint is here made; and if these qualities are generally attached 
to. physicians, then it is in their power to abate the evil throughout 
the population in general. 

Can there exist any reasonable doubt that the country is 
abundantly supplied with well informed physicians ; seeing that 
the land is filled with members of the profession, who have en- 
joyed the best possible opportunities of storing the mind with all 
the lines and precepts of medicine, delivered down through a 
succession of ages, continually productive of ameliorations in the 
doctrines and the arts of curing disease? But such persons as 
these are worthy of the public confidence, both as to their morals 
and their understanding. They are, in general, worthy repre- 
sentatives of the style and character of the gentleman, and, 
therefore, capable of attracting the confidence of such as are 
under suffering. 

I have met to-day, April 9th, 1847, with a case which shows 
how far the fastidious delicacy existing in the relation betwixt 
the sexes may be carried to the part of the physician. A lady, 40 
years of age, consulted me as to a painful menstruation she has 
had for twenty years. She experiences severe pain and dis- 
agreeable weight and pressure in the loins and hypogaster, and 
pain in the head for five or six entire days before each menstrual 
period ; all which symptoms disappear with the first gushings of 
the evacuation. She represents her health to be the same now 
as for twenty years past. Hence, I presume, there has occurred 
but little change in the physical condition of the parts, else there 
would be some change in the sensations arising from the malady. 



EMBARRASSMENTS IN THE PRACTICE. 21 

She has been repeatedly subjected to the taxis ; but no one 
ever examined the os uteri with the speculum until to-day. Well, 
that examination reveals a certain state of the cervix and os uteri, 
and glands of Naboth, &c, which it was indispensable to know, 
in order to found a rational treatment. The delicacy existed, not 
on the part of the lady, but on that of the medical advisers; for I 
have her assurance, that her sufferings, both bodily and mental, 
have been so great, that she should long ago have submitted to 
any means of even a probable cure ; and was, indeed, always 
desirous to have everything done that was possible in her be- 
half. I doubt not this lady might have been cured long ago, 
had her malady been thoroughly understood. 

I have mentioned this case to show that the physician is in 
fault when he does not do his whole duty; for it is incumbent on 
him to leave nothing undone that may aid and comfort his patient. 
But let us return to our remarks upon the qualities that ought to 
distinguish the medical man. 

I think that, in order to be a physician, one ought to enjoy 
strong perceptive faculties ; he should be able to make nice dis- 
criminations ; quickly perceiving the slightest shades of difference 
in all material forms, superficies, colours, weights, and resistance. 
The faculty of judging between the relations and differences of 
things should be of the primest quality; not sudden, hasty, and 
impatient in its operations, but slow, dispassionate, and attentive. 

The mind and heart of the practitioner ought to be the shrine 
of truth and probity ; his mind should not deceive itself, and his 
heart should not suffer itself to be deceived and misled, by any 
earthly temptation, from the narrow and rugged way of duty and 
conscientiousness. 

His intelligence ought to be vast, as acquainted, very generally, 
with what is called knowledge and science by mankind. Par- 
ticularly should he be fully informed as to the nature of the Life- 
force, as displayed in the various tissues and organs of any ani- 
mal economy ; not in that of man alone, but in the whole zoo- 
logical series, as well as in the vegetable kingdom of nature. 

There ought to be no function of the economy, or of its parts, 
whose healthy rate he could not estimate, as well as all its devia- 
tions in sickness. But this is not all — he ought to be able to 
discern, not the signs only of maladies, but the tendencies of 
these maladies; as whether they possess a certain tendency 



22 EMBARRASSMENTS IN THE PRACTICE. 

towards recovery, or a tendency towards destruction; so as to 
enable him to say, as he does of a vaccine inoculation, let it 
alone, it requires no remedy, it carries the cure in its own nature, 
it will have disappeared, with all its phenomena, on the eighteenth 
day. Or, on the other hand, take care of that headache ; she is 
pregnant, and near term; know that such a headache is but a 
step removed from an eclampsia; and that an eclampsia is 
often the penultimate phenomenon of life. Let that case alone — 
cure this one. 

Do you not perceive, young gentlemen, that such a physician 
is not of necessity a doser, a druggist ; and that in a great moiety 
of the cases in which he is consulted, the patient will escape all 
physic and be cured by wise counsel — and likewise, that when 
therapeutical interference is required, he will know what to do, 
what medicines are required, and when, and how much ? 

It is often dangerous to ask a physician the question, what 
shall we do? because habit, custom, routinism, almost always 
compel him to say take — take. 

He ought to be familiar with the doctrines of a good Medical 
School ; by which I mean, not the doctrines of the University of 
Pennsylvania, or that of New York, or Maryland, or London, or 
Paris, nor the Jefferson College, but a school which has taught 
him a demonstrative anatomy, a real eclectic physiology, a 
sound and philosophical chemistry, &c. A school, in short, 
which has set before him, in full array, the results of man's 
achievements in medical investigation, experience, and art; leav- 
ing him, out of his own clear, sound, honest, and capacious intel- 
lect, to become capable of saying, as to any case of disorder pre- 
sented for his opinion, such is the malady, its tendencies are thus, 
or so, its treatment requires such and such methods. Let him 
judge the case by the case, and by no other law or evidence. 

Let him not be a methodist — let him be a man of principles in 
medicine ; principles, which, like the genii of the Persian fable, 
come at his bidding and do his bidding, for no one can be taught 
to cure diseases by a method. Method in medicine is beneath 
contempt; because, owing to the infinite variety and differences 
existing among the living molecules that are the subjects of the 
vital forces, there never were, nor can be, two absolutely similar 
cases. Each instance is an integer, and should, in strictness, be 
so deemed, and studied, and understood, and managed upon a 



EMBARRASSMENTS IN THE PRACTICE. 23 

reference to it, and not to another integer. It is true that the 
patient who is under care to-day, may be like "him who died 
o' Wednesday," but is not him. Hence, you perceive that I am 
no admirer of statistics except for the government, where statisti- 
cal returns of agriculture, commerce, manufactures, crime, popula- 
tion, &c, are useful to the statesman for making his assessments, 
his calculations, and his levies ; but when I treat a case of pleu- 
risy, I do not care how you treated your case of pleurisy ; I shall 
bleed my patient on account of his fever, pain, cough, dyspnoea, 
&c, and not because you bled your patient, who had similar 
symptoms, of the gravity of which I am no judge, not having 
been present to judge. So, if I treat a female with certain pain 
about the middle of the sacral bone, with dysuria, or retention of 
urine, &c, by methods calculated to take the strain off from her 
ligamenta rotunda, and thus cure her of retroyersio uteri, what is 
it to me that you adopted some other mode ? That which inte- 
rests me is, to be sure that a woman, who has ligamenta rotunda 
not more than two inches and a half long, cannot have her womb 
turned topsy-turvy. That is the principle which I ought to ap- 
prehend, and I shall carry it out in my practice. Do you get 
some other principle, if you can, and come to prove my error by 
your statistics ; I should be strongly inclined to take after Mr. 
Dennis Bulgruddery, in the play, who, if bothered with statistics 
by his friend Bull, would have been sure to say, " To the divil 
I pitch you and your statistics, Mr. Bull !" 

Let a man, therefore, make himself so thoroughly learned in 
medicine that he can detect the lesion of structure or function 
wherever it may hide, and then he is the sole judge of the action 
required in the case. Not because twenty other cases were, but 
because this case is. 

But I stated that one great cause of unsuccess, is in the absence 
of information among the population generally. This absence of 
information is the fruitful source of Homoeopathy, Hydropathy, 
Thompsonianism, Panaceaism, and all the Catholicons, Infallible 
worm destroying lozenges, Balms of Gilead, and that shocking 
absurdity — the Vegetable pill, which, like a sort of epidemic diar- 
rhoea, has tormented the intestinal canal of thousands and tens of 
thousands of our far-seeing compatriots, until the American popu- 
lation have become hardened in. purgations. If Horace were 



24 EMBARRASSMENTS IN THE PRACTICE. 

here, he would not think the dura messorum ilia the toughest 
things in creation. 

Do you suppose, my dear young gentlemen, that if the com- 
munity at large should be as well acquainted with physiology and 
therapeutics as you and I, the Ledger and the Gazette would 
occupy nearly one-half of their columns with those horrid descrip- 
tions and unblushing confessions of piles and itch, and other 
dreadful disorders, which the sufferers under them love to parade 
for the public gratification and improvement, under their own 
signs manual in the Gazette? 

You, who know the skeleton humanum, and the attitude of the 
uterus within the pelvis, do you think that Mrs. A. to X. would, 
out of a missionary zeal, suffer her name to appear as one of the 
wonder- worked cures of a shameless procidentia, by what is, at 
our daily breakfast-table, brought up in the morning paper, to 
stare the ladies out of countenance, under the modest title of 
a utero-abdominal supporter. Who wants to know, or ought to 
know that the ladies have abdomens and wombs but us doctors ? 
When I was young a woman had no legs even, but only feet, and 
possibly ankles; now, forsooth, they have w^ero-abdominal support- 
ers, not in fact only, but in the very newspapers. They are, 
surely, not fit subjects for newspaper advertisements, nor would 
they be advertised but out of our own stupidity or remissness. 

I say, confidently, out of our remissness, and here are my 
reasons for saying so. 

This is a land and an age of common schools and common sense. 
This is a country of general knowledge among the population. It 
is impossible that any system of science or art can stand in this 
country, flooded as it is with intellectual light, sustained by any 
but real claims to the respect and confidence of the public. We 
doctors claim this confidence and respect ; and we deserve it, 
doubtless ; but we claim it imperiously and as a vested right, as 
a right descended to us by inheritance, from our avos et proavos, 
the founders of our order. But we ought to remember that our 
privileges, those we received in a commission proceeding from 
the Legislature, under the Great Seal of the Commonwealth, are 
not of the nature of the privilegium clericale, as the lawyers term 
it. There are too many persons in this country that can read 
and write, to allow us to claim a clergyable exemption from the 
general practice here of explaining one's self. What is the right, 



EMBARRASSMENTS IN THE PRACTICE, 25 

therefore, by which we assume, in the present day, to clothe all 
our proceedings in mystery, and to expect our patients to kneel 
down while we, (not confess, but) cut them with bistouries and 
knives, or put arsenic and prussic acid down their gullets ? They 
will not submit to our clerical manners ; and they say, that if we 
persist to hide our art under an impenetrable veil of mystery and 
jargon, they must continue incapable of discriminating betwixt 
the true physician and the quack-salver, since both agree upon 
one course, that of demanding an implicit faith and obedience 
without recourse to reasoning. Is not this representation a fair 
one ? Even your early and noviciate experience must, w T e think, 
have furnished you the materials for judging whether I speak 
fairly or not. 

I say then, it is our stupidity and remissness that work evil to 
the people, and redound to our own hurt also; for there is no 
person, endowed with a good share of common sense, to whom 
you could not address, through that common sense, a reasonable 
and plain statement of the facts of his case, the probabilities as to 
its course, duration, and end ; with an enumeration of the safest, 
most convenient, and certain processes for its cure. Imagine 
such a person, well-informed, and you have the idea of a patient 
the most docile, the most exact in therapeutic and hygienic obe- 
dience; the most confiding in your skill, and the most grateful 
for your intervention in his behalf. Would that all our brethren 
in this land might adopt views like these. With their united 
force of intellect, of character, of beneficence, and of social station, 
it would be but a short time e'er the diminished head of charla- 
tanism, under whatever disguise, would be found only to lift 
itself up among the most ignorant and abject portions of the 
population, instead of riding, as it does to-day, with chariots and 
with horsemen, a shame to the intelligence of the age, and a per- 
petual eye-sore to the lover of truth, and contemner of every 
species of imposture. Let us explain ourselves then to the 
people. 

I hope it will not be deemed impertinent in me to say to you, 
that I have enjoyed a large share of professional business for 
some years past, and that, in the main, I have had reason to sup- 
pose I received very unbounded confidence, and a general obedi- 
ence to my medical directions, from those persons and families 
who called me. This good fortune I have long attributed, in a 



26 EMBARRASSMENTS IN THE PRACTICE. 

considerable measure, to the entire frankness of my explanations 
as to any diagnostic, prognostic, therapeutic, and hygienic views 
in my cases; as well as the pathology of them. 

Some of the brethren, chiefly, I presume, those who have not 
very clear and concise views of their own on medical topics, are 
bitterly opposed to all explanation, on the ground that our princi- 
ples of science are too recondite for the vulgar to be able to appre- 
ciate either them or the facts on which they rest. I have occasion- 
ally met with difficulties, in consultation, from the opposition of 
some of the brethren to my desire- to let the patient fully into my 
opinions. If a man really have any opinions, that are honest 
and clear, and well founded, why should he conceal them ? I 
confess my belief, that where a physician forms perfectly trans- 
parent views of his cases, there is no need for the powdered wig 
and the gold-headed cane, the mysterious nod, and all the appa- 
ratus of deception that we might look for rather in old Felix Plater, 
or Horace Augenius, than in a modern physician, who is, or 
ought to be, a modern gentleman and man of honor ; and, as 
such, above all false pretences — open, candid, and manly. 

Now, I sincerely believe, that where you desire to effect a cure, 
and you meet with obstruction through the timidity, the doubts, or 
apprehensions of the patient, you will only have to speak common 
sense, and to take out your pencil, and, on a sheet of paper, 
make a few well sketched diagrams of parts, organs, and rela- 
tions of parts and organs, in order to bring the recusant back to 
a truer and firmer faith than before, by convincing his judgment 
and winning his inclination. Yea, verily, you shall sustain the 
fainting hope and the dying faith of the sick girl, for days and 
for weeks, and through months of pain, if you speak the truth 
and explain the truth ; if you show the hope and have the hope ; 
if you explain the power and really possess it. 

If you have not the confidence of your patients, it is because 
you either do not merit it by your science, your skill, and your 
temper; or because possessing all these, you are destitute of, 
what I beg you to excuse me for calling in a grave book by a 
slight term, gumption. Depend upon it, my dear young gentle- 
men, there are plenty of people, "plenty as blackberries," who 
are very learned and very shining, except when you come to rub 
them, and who lose all shining quality, because they have not 
and cannot take a real polish. 



EMBARRASSMENTS IN THE PRACTICE. 27 

The celebrated Dr. Clarke, of London, from whose lectures that 
capital little midwifery book, called the London Practice of Mid- 
wifery, was pirated, says, somewhere in its pages, that one Doc- 
tor, by his good sense, shall retain the entire confidence of the 
woman in labor through the most painful protractedness, while 
another would lose her confidence, in a very short time, of hope 
deferred; and that, not because he hath not ability as a pre- 
scriber equal to the other, but from some fault of manner, expres- 
sion, or conversation. 

If you would be learned men, it is well; but it is better to be 
wise men. A man may be wise without being learned ; but it is 
not uncommon to be learned, and yet to be a perfect ass in all 
that relates to what I might term administration, or action. Let 
your light, therefore, shine among men, and do not conceal it 
under a bushel of gawkeyness ; or some stupid conceit of your 
personal dignity; or, what is still more asinine, the dignity of your 
calling. Dignity is you, not physic, nor the practice thereof. 
Did you never hear that 

" Worth makes the man, the want of it the fellow, 
And all the rest is leather and prunella?" 

I have seen dignified shoemakers, carters, butchers, and even 
a very dignified tailor, and I have known philosophers and very 
learned men without dignity. Believe me, there is true dignity 
in great virtue, great information, and great power to diffuse, 
apply, and make that information useful to our fellow men. Such 
is the dignity you should strive to attain. 

If I could give you the best piece of advice in my power, I 
think I should give you this advice; namely, in all your dealings 
with mankind as physicians, and in all your life-doings, strive, 
first, to increase the boundaries of your knowledge ; and, second, 
strive to make that knowledge as vulgar, as popular as possible. 
Be a reformer in this particular, and you will, should you suc- 
ceed, become the real founder of a Sect in medicine, and that 
sect you may baptize as the Young Physic that Dr. Forbes advo- 
cates. That will be the true young physic, which succeeds in 
bringing down Old Physic to the level of this common sense age. 

I say again, therefore, wherever you place yourself, be sure to 
have no concealment, no mystery, no pretence ; but endeavor, 
in the clearest manner, not to assert, but to show vour claims to 



28 EMBARRASSMENTS IN THE PRACTICE. 

superior powers in that great utilitarian avo cation of curing the 
sick and the wounded ; an avocation which is almost, I say it 
with reverence, next in goodness to the mission of Christ, who 
went about clothed with power and authority, — sysipsiv *ov$ vsxpovs 

xal ^aortoieiv. 

In order fully to discharge the duties of this great mission, is it 
not indispensable that you should prepare yourselves for its offices 
by suitable preparation of the mind and person? Of the mind, by 
arming it with knowledge and wisdom, with prudence and pa- 
tience, with firmness to encounter all vexation and responsibility, 
with charity and liberality, and with all that armature of the soul 
which alone can render men worthy to be called Asvflepot, for 
none are so but those whose condition has raised them above 
the grossness and sensuality of the corporeal nature, rendering 
the body the servant and the minister, not the tyrant of the soul and 
the heart, that ought to "sit lightly on Reason's throne;" not 
as crushing, but adorning the intellect with noble sentiments. 

It is difficult to say how a man, in forming his manners, should 
proceed. Indeed, there is, probably, no art so great to form the 
manners as that which teaches us to keep the temper and the 
desires of the soul within the just bounds within which it is con- 
tained among all true followers of the Christ. To be a true and 
accomplished gentleman, one should " do justly, love mercy, and 
walk humbly before God." Any person, under such guidance, 
cannot fail to have manners acceptable in all forms and ranks of 
society, where business may present him. 

A special regard to one's person is also a very indispensable 
means of success, not in making money, but in curing the sick. 
The sick are affected by the presence of the physician. One well 
dressed, of good manners, of agreeable conversation, neither too 
grave nor too gay, would, cceteris paribus, inspire more confi- 
dence, infuse larger courage, longer patience, and greater hope, 
and therein succeed more surely in curing his patient, than an- 
other of equal information on medical science, but careless and 
negligent of his behavior and appearance. 

I cannot advise that you always should carry about with you 
an air, and, indeed, a habit of boasting, and an appearance of 
self-sufficiency, which, wherever they are observed, generally are 
taken to be signs of weakness. But that which you do know, I 
would have you conscious of knowing, so that you may be en- 



29 

abled to speak, with due boldness and decision, on all proper 
occasions. 

But, alas! gentlemen, I fear I am uselessly consuming your 
time and exhausting your patience. I shall close this letter, 
therefore, by recommending you to observe the rules of conduct 
laid down by your Professor of the Institutes on commencement 
day. Should you remember and follow out the plan he then 
pointed out, you will become what I desire ardently that you should 
become, useful and successful in your calling, which will redound 
not only to your own honor and profit, but to the credit of your 
Alma Mater. 

Before I close this letter, pray allow me to cite for your perusal 
a passage from Sir Thomas Browne's Religio Medici, p. 139, 
who, if you imitate him in the sentiments and conduct here 
pointed out, will be your sufficient model. 

"I feel not in me," says Sir Thomas Browne, " those sordid 
and unchristian desires of my profession ; I do not secretly im- 
plore and wish for plagues, rejoice at famines, revolve epheme- 
rides and almanacks, in expectation of malignant aspects, fatal 
conjunctions, and eclipses : I rejoice not at unwholesome springs, 
or unseasonable winters ; my prayer goes with the husbandman's ; 
I desire everything in its proper season, that neither men nor the 
times be put out of temper. Let me be sick myself, if some- 
times the malady of my patient be not a disease unto me. I 
desire rather to cure his infirmities than my own necessities: 
where I do him no good methinks it is scarce honest gain ; though 
I confess it is but the worthy salary of our well intended endea- 
vors. I am not only ashamed, but heartily sorry, that besides 
death there are diseases incurable ; yet not for my own sake, or 
that they be beyond my art, but for the general cause and sake 
of humanity, whose common cause I apprehend as mine own." 
Farewell. C. D. M. 



30 ^ex. 



LETTER III. . 

SEX. 

You may remember that in lectures at the college, I very fre- 
quently repeated that the ovary of the female gives to her the 
sexual character, and that as the interior and active tissue of the 
ovary, is the part which Ch. Ernest von Baer calls the lager or 
stroma, so that very lager or stroma is the Sex itself. 

You might, perhaps, at first hearing this dogma, feel disposed 
to reject it as too concise an expression of the multitudinous 
and diversified characteristics of the sexual nature — but I hope 
a careful examination of the matter may induce you to coincide 
with me in opinion. 

The sexual office is designed to reproduce the material forms 
and faculties of a genus or species; and this is not done save by 
the production of a germ, which at least, in all the Zoological 
series, is found within an ovum, which, in plain English, is an 
egg. Omne vivum ex ovo, is a true saying. 

An ovum then is an egg — which is not to be considered as a 
germ, but as a thing containing a germ and the material or 
pabulum for the early stages of the development of that germ. 

An egg is a yelk-ball — which in some instances is invested 
with a quantity of albumen or white, and in some cases is not 
accompanied with any deposit of that sort. 

The yelk-ball is a vitellus — and consists of a multitude of cor- 
puscles and granules, and punctiform bodies and small globules 
of oil swimming in a clear delicate fluid, inclosed by a delicate 
anhistous membrane, the vitellary membrane. In most cases 
yelk is of a yellow hue, in some it is red or greenish, &c. 

If you break open a yelk, whether of the humming bird or the 
ostrich, of the elephant or the mare, the rabbit or the earthworm, 
the shad, the minnow, or the whale, you will find it to consist of 
corpuscles, granules, and puncta, with oil globules and the clear 
fluid. 

If the egg has not been subjected to fecundation, as it cannot 



"sex, 31 

be within the ovary, there will be found within it at the centre of 
the ball, or near the surface of the vitellary membrane, a smaller 
spherule of a beautiful transparency, and which is denominated 
the germinal vesicle— within which, adhering to the wall of the 
vesicle, are a number of very minute microscopic granules, which 
by Rudolph Wagner, of Berlin, by whom they were discovered, 
are called the macula germinativa or germinal spot— so that an 
egg is: 1, a vitellus ; 2, a germinal vesicle contained within a 
vitellus; 3, a germinal spot lodged upon the inner wall of the 
germinal vesicle. 

Is it not to be believed that the germinal spot is the true germ- 
point, or germ itself, and that all the other constituents of the 
ovum are placed round about it, in order that by its changing and 
formative power, its metabolic and plastic force, it may convert 
their elements into its own corporeal elements, evolving by their 
consumption the rudiments of its own organs, as brain, veins, heart, 
blood, &c. &c, until, having acquired sufficient organic form and 
force, to make its mesenteric attachment to the living parts of 
the womb — it is ready to be conceived : conception being the 
formation of that mesenteric attachment, and nothing more nor 
nothing less. 

Nature, all whose operations are preordained, as being guided 
and limited by the law of God, has provided fully and most 
liberally for the production of germs, and thereby secured the 
perpetuity of her kinds. She has, in order for this germ pro- 
duction, adopted various methods of arrangement. In certain 
animals she has devolved the germ-producing and the fecundat- 
ing powers upon the same creature — in others, she has provided 
two independent forms of being for the carrying on of the office. 

In the lower orders of beings, as the earthworm, for example, 
both the germiferous and the fecundative attributes are com- 
prised within the same individual body. So that the creature 
can fecundate its own female constitution by the act of its male 
constitution ; and this simple but effectual mode of keeping up 
the genus or species, is admirably adapted to the inactive and 
aperceptive nature of the being itself. 

In higher forms, two separate individuals are provided, one 
with the male, or fecundating nature, and the other with the 
female, or germinating nature. "Male and female created he 
them," unto the end that they might increase and multiply, and fill 



32 THE OVUM. 

the earth with sentient beings, wonderfully endowed with life- 
faculties, and therefore with the means of enjoyment, in other 
words, of happiness. To procure happiness and establish it, 
must be regarded as one of the highest attributes of Divine power 
and beneficence. 

The important, the indispensable ovum, could not be left with- 
out protection — it could not be developed without a machinery. 

The ovum is, therefore, protected with an ovisac, or capsule, 
which is what is called a Graafian vesicle, or Graafian follicle or 
Graafian cell, from Regnier de Graaf, a Dutch physician, who, 
in his Treatise de Mulierum Organis Generationi Inservientibus, 
published in 1672, gave the first clear account of those small 
pellucid vesicles that you have so often seen in the ovaries I 
exhibited to you. 

A Graafian vesicle consists of a double-coated capsule, of 
which the outer one lies in contact with the stroma, and contains 
the inner one within its own sphere; not loose and unattached, 
but connected to it by means probably of a very delicate lami- 
nated cellular tela. 

This interposed and connecting cellular tela may become filled 
with secretions ; and as the outer one is, like a mineral in its 
gangue, pressed against the stroma, it is clear that any interstitial 
deposit must have two contrary results, one to enlarge the outer 
concentric and throw it back against the stroma, displacing and 
distending it, and the other to press the ovisac inwards towards 
its contents to compress them, and to render the inner aspect of 
the ovisac uneven, wrinkled, or convoluted ; and, in fact, I have 
shown you on several occasions both these different results. 

I pray you call to mind, not only the human ovaries in which 
I showed you the convoluted or wrinkled appearance of the 
inner aspect of the ovisac, but the more striking samples of the 
same effect in the ovary of the cow. In this latter case the inter- 
stitial deposit was so enormous, that the outer coat of the ovisac 
had grown to a size nearly equal to half the mass of the whole 
ovary, and was of an orange hue, derived from the deposit of a 
vast quantity of vitellary matter betwixt the two laminae ; the outer 
one being greatly expanded or extended, and the inner' one being 
crumpled, convoluted, or wrinkled. This great orange coloured 
mass was the corpus luteum. 

Before the corpus luteum had begun to form, the ovary had been 



VITELLUS, CORPUS LUTEUM. 33 

occupied in furnishing vitellary matter for the constitution of the 
yelk-ball; but that ball, having become complete in all its parts, 
and incapable of any further accretion, as contrary to its generic 
law, the ovarian stroma, whose office it is to produce germs and 
vitellus, could not at once withhold its vitelliferous power, and 
the deposit went on upon the outside of the ovisac. 

Hence, you perceive that in a perfectly mature Graafian folli- 
cle, there is a yelk-ball with its germinal vesicle and germinal 
spot inside of it ; some fluid of the ovisac filled with granules ; 
while on the outer surface of the ovisac, between it and the ex- 
ternal capsule or coat, is a yellow deposit, which begins to ap- 
pear there about the time when the yelk is quite ripe, and con- 
tinues to augment in quantity for some time after the yelk has 
been discharged. Let me repeat, that this yellow body is the 
famous corpus luteum, and that such a yellow mass is deposited 
with the maturation and discharge of every yelk. Sometimes, 
perhaps, in pregnancy, the corpus luteum is larger than at other 
times, but whether large or small, it is a real corpus luteum ; 
for there are not, as some writers pretend, true and false, but 
only true corpora lutea. 

But this gradual evolution of the luteal deposit has the effect of 
lifting the germ, with its vesicle and its yelk-ball, nearer and 
nearer to the superficies of the stroma ; to press outwards the 
tunica albuginea ; and, finally, to press it so forcibly, that absorp- 
tion commences at the weakest and most distended point of its 
surface, until, a pore being formed, the yelk and the fluid about 
it, escape from their imprisonment in the ovary, and fall into the 
belly, or are received within the infundibular orifice of the ovi- 
duct, which you call the Fallopian tube, and thence conveyed to 
the womb. Its mesenteric attachment to the womb, as I before 
said, constitutes a conception, which pregnancy follows. 

I have made the foregoing observations in order to fortify my 
assertion, that for the female, stroma is sex. 

Do you think that if a creature should be born with the external 
genitalia perfectly well formed; with a perfect uterus, and vagina, 
and tubes ; but without the trace of any ovarium, such a creature 
could be a female ? Or, if she should have two perfect ovaria, 
and be born without womb, or vagina, or external organs, would 
she be anything else than a female ? I am sure you will agree 
with me, that she would not, in the former case, be female, and 
3 



34 sex. 

that, in the latter, she would be truly female — because, though 
unhappily deprived of any gestative organ, or organ of copulation, 
she is endowed with the germiferous, through her vitelliferous 
faculty, which resides essentially and exclusively in the substance 
called stroma. No germ could she evolve in the spleen or liver, 
in the kidney or brain, in the heart or lungs, nor, indeed, any- 
where, save in the stroma, which is the true sexual concrete, and 
is, therefore, itself sex; for liver, heart, brain, lung, nor digestive 
canal, is not sex, but stroma is sex for the female — nothing else 
is sex. 

But, after all, what is sex ? Methinks you ask the question, 
which is a very difficult one. Perhaps I should best answer it in 
a few words, by saying it is reproductive power, whether male 
power or female power. It is a matter of indifference whether 
the philologists derive the word from secus, aliter, otherwise, 
after another manner; or from secare, to cut, to divide one from 
another. We have, in physic, less to do with philology than with 
facts. I consider that we are hitherto unacquainted with any 
facts that give convincing proof of a sexual nature in the germ. 

There is an embryonal stage of life in which it is utterly im- 
possible to determine the sex of the embryo ; and it is not known 
whether the female embryo proceeds from a germ originally 
female, or whether the germ, being in its inchoate state, neither 
male nor female, assumes the female nature in the progress of its 
evolution, or takes on the nature of the male, under some law as 
yet unknown to us. 

It is very certain, however, that for the human race, the pro- 
portion of the sexes, as to their number on the globe, is main- 
tained from age to age. The law that ordains this equable rate 
of production, operates so as to bring into the world about 104 
males to 100 females; a proportion which keeps the sexes nearly 
equal in number; it being supposed that the temperament and 
exposure of the male render him more liable to premature death 
than the female, on which account the excess of males is or- 
dained. 

If we refer to what is known to occur as to the non-sexual 
nature of the larva of the bee, hereafter to be mentioned, we may 
find arguments for the opinion that the germ, originally, is non- 
sexual, but becomes male or female under some unknown law of 
development, in its earliest embryonal life. 



sex. 35 

If such a sentiment may be rightfully entertained, you will, 
perhaps, agree with me that the sex is something superimposed 
upon the mere living nature of a creature ; and you will more 
readily admit of it if you contemplate two children, one male and 
the other female, of the same stature, weight, and temperament, 
born at the same hour, and brought up at the same breast. You 
cannot report to the mother of what sex they be, without referring 
to the pelvic extremity of the trunk. They are pleased with 
the same rattle, tickled with the same straw. They play at the 
same toys, and are alike, in moral and physical attributes, until 
the sexual endowment comes to be granted to them. Upon that 
instant they divaricate; their whole physical, and intellectual, 
and moral forces become different, and they pursue, so to speak, 
a separate walk of life, until the exhaustion of the sexual attri- 
bute, in the one and in the other, causes their paths to converge 
again, until they are seen sleeping " thegither at the foot" of the 
hill of life, over which they had toiled in distinct tracks from the 
puberic until the critical age. What can be more like an old 
woman than an old man? or what can be more like a girl than a 
perfectly ingenuous boy? Where is the likeness of men and 
women ? 

Is it not true, then, that the sexual nature is something super- 
added to the mere living corporeal nature, which, on being taken 
away, reduces them back again to their original sameness of life- 
nature ? 

t You have heard, I presume, of a circumstance that may tend 
to illustrate this view, in the history of the honey-bee. The com- 
munity requires a queen — which means a vitelliferous, and so a 
germiferous creature — and it also requires a considerable number 
of drones — males, or fecundating members of the society ; which 
being provided for the hive in question, nothing more' is wanting 
but a sufficient number of mules, or working bees, or creatures 
capable, first, of enjoyment, and second, able to provide for the 
conservation of the species by collecting food — 1, for the germi- 
ferous; 2, for the fecundating; and 3, for the providing part of 
the species. Now, all these males and workers are alike in the 
ovular state; but if the males die, by some epidemic, a battle, 
or accident, the community know how to convert the larva? into 
males by administering to them certain sorts of food, or to leave 
them mere workers by withholding that kind of aliment. So 



36 sex. 

that, in fact, you discover here that the mere corporeal life of the 
larva possesses no sexual nature, and that a sexual nature may 
be superadded by a certain economy of the hive, an economy 
that can cause the ovum so to develop itself, as to become fitly 
provided with the fecundating apparatus and material, or to become 
a queen bee, or germiferous bee ; for, when a queen dies, after 
having deposited many thousand eggs in the mule bee cell, the 
alarm and confusion in the hive are very extraordinary, but it 
subsides after the tumult of the first excitement, and the mules 
or workers select some one egg, for which they enlarge the cell 
by converting three common ones into a single royal cell ; and 
then, by feeding the grub with an aliment called royal jelly, they 
cause it to pass into the female state, and thus the lost queen is 
succeeded by a queen produced from the egg of a mule or 
worker-bee: an egg that could only have developed a non-sexual 
creature but for the special influences brought to bear upon it 
from a state necessity. I ask you again, if this be true, whether 
it does not show that the sexual nature is not an original nature, 
but a nature superimposed upon a mere animal or living nature. 
And, if true of the bee, does not that truth established, likewise 
establish the law for all possible animal and even vegetable 
existences ? 

I see not how a better proof, or, at least, illustration, could be 
given of my idea, that the sexual nature is a climax ; it is a 
culminating life-force that evolves it. 

It ought not to excite our astonishment that the female sexual 
nature gives to her physical, intellectual and moral attributes, 
a bias different from that of the male. 

Her organs are different — they are subject to fluctuations as to 
the tide of life within them that those of the male are by no 
means exposed to. They require a different and more complex 
system of innervations, more expensive to the nerve centres than 
those of the male; more delicate, sensitive, impressible than his. 
These are circumstances implying a dependence and physical 
debility as compared with him ; a reliance and trusting to his 
power; and, in fact, all the peculiarities that mark her as a crea- 
ture of the feminine and gentle sex. 

I shall, in my next letter, occupy your attention with some 
remarks on the distinctive characteristics of the female, to which 
I shall beg to invite your attention, not with a view that you may 






THF FEMALE. 37 

learn of me what those distinctive characteristics are — for a volume 
would not suffice fully to relate them — but that I may, perhaps, 
be able to turn your attention in that direction, in the hope that 
your young and vigorous strength may be incited to a more con- 
sistent and energetic pursuit of whatever literature and science 
ought to be garnered up by a physician, as the ornaments and 
aids of his career of usefulness and dignity. Farewell. 

C. D. M. 



LETTER IV. 

SEXUAL PECULIARITIES. 

Gentlemen: — Before I proceed to the consideration of those 
topics which are to engage our attention in the main, I wish to 
take advantage of this occasion to say some words to you on the 
Distinctive Characteristics of the Female — or rather, I should say, 
on some of them — for to describe them all, would require tather 
a series of letters than a single discourse. I shall, therefore, in 
the present letter, attempt to indicate only a few points of contrast 
betwixt the male and female, with a view to turn your attention 
that way. I could readily fill a volume upon the different texts 
that I am about to present to your consideration. 

It is proper, I believe, that I should fulfill this design, for I have 
long thought, as I now do, that without some prefatory remarks in 
this direction, you might be less fully prepared to receive those 
views of the disorders to which the woman is subject, which it 
behooves you as medical men to acquire; and less capable to 
appreciate those modifications of therapeutical indication and 
process that are demanded by the moral, the intellectual, and the 
physical qualities of the female; for her mere human, or generic 
nature is modified by her sexual or female nature, to such a de- 
gree, that in certain of the great crises of her life, she demands a 
treatment adapted to the specialties of her own constitution, as a 
moral, a sexual, germiferous, gestative, and parturient creature. 

I do not suppose you could acquire just views on these points 
in the dissecting-room, or the theatre of anatomy alone. Nor can 



38 THE FEMALE. 

I give them to you here in one letter; the time is too short. 
There, it is true, you might explore the items of her physical 
structure, in order to compare them with those of the hardier sex. 
You might there learn that though she be a part of mankind, a 
truer Zygozoaire than those of M. de Blainville's classification, 
she yet differs from men in her stature, which is lower; in her 
weight, which is less ; in her form, which is more gracile and 
beautiful; in her reproductive organs, that are peculiar to her ; 
and in her intellectual and moral perceptivity and powers, which 
are feminine as her organs are. 

Beyond all these, you shall have to explore the history of those 
wonderful functions and destinies which her sexual nature en- 
ables her to fulfil, and the strange and secret influences which 
her organs, by their nervous constitution, and her functions, by 
their relation to her whole life-force, whether in sickness or health, 
are capable of exerting, not on the body alone, but on the heart, 
the mind, and the very soul of woman. 

The medical practitioner has, then, much to study, as to the 
female, that is not purely medical — but psychological and moral 
rather: such researches will be a future obligation lying heavily 
upon you, upon all of you. 

Every well educated medical man ought to know something 
more of women than is contained in the volumes of a medical 
library. Her history and literature, in all ages and countries, 
ought to be gathered as the garlands with which to adorn his tri- 
umphant career as a physician ; but these insignia of his power 
he can only gather by the careful and tasteful study of his subject 
among the rich stores of learning that are gained in the belles- 
lettres collections, whether archaiological, mediaeval, or modern. 

The medical man, surely, of all men, ought to be best able to 
appreciate the influence of the sex in the social compact. But 
for the power of that influence, which one of you would doubt the 
rapid relapse of society into the violence and chaos of the earliest 
barbarism ? 

Are you not aware that the elegance and the polish of the 
Christian nations are due to the presence of the Sex in society — 
not in the Zenana! Do you not perceive that Music, Poetry, 
Painting, all the arts of elegance : Luxury, Fashion, (that potent 
spell!) are of her, and through her, and to her 9 Versailles and 
Marli, and the Trianons, had never been built for men. The 



THE FEMALE. 39 

loom blends and sets forth the dyes that add richer reflections to 
her bloom ; the wheel flies for polishing the diamond that is to 
flash in impotent rivality above her eyes; sea and land are ran- 
sacked of their treasures for her; and the very air yields its 
egrets, and marabouts, and paradise-birds, that they may add 
piquancy to her style, and grace to her gesture. Even literature 
and the sciences are in a good measure due to her patronage and 
approbation, which is the motive power to all manly endeavor. 
This is true, since, but for her approving smile, and her reward- 
ing caress, what is there should stir man from the sole, the dire, 
unremitted compulsion to act that he may live ? With woman 
for his companion, he acts not only that he may live, but that he 
may live like a Christian and like a Gentleman. 

K Blest as the immortal Gods is he, 
The youth who fondly sits by thee, 
And hears and sees thee all the while, 
Softly speak, and sweetly smile !" 

The great stage of the world, we are informed by the inspired 
writers, was prepared as the scene of a grand moral drama. The 
earth and all that it inherit is for man, his use, his delight, his 
trial! But, this mankind — this genus man — what is it? It is an 
imperishable unit — it commenced at the beginning — it touches 
the middle and the end of time. It is a vast wave rolling down 
the tide of time, ever rolling, ever descending. Its spray and its 
foam are lost in the sands or melted in air, or the fragments of its 
mortality are broken off and swallowed up in the grave ; but the 
unit is unbroken ; the wave rolls onward, onward forever ; per- 
durable ; and shall not be swallowed up till the last trump shall 
sound, and the last end be come. The sun himself " grows dim 
with years," but the unit, the Genus man, springs ever fresh in 
immortal youth and vigor, like Antaeus of old, foreshowing the 
immortality of that spiritual part to which Adrian the pagan ad- 
dressed his speech, as it was leaving the imperial possessor a 
mere dust-fragment of the vast, ever-living unit man. 

Animula vagula blandula 
Hospes comesque corporis, 
Quae nunc, abibis in locis. 

Ael. SjPARTiANrs. — Adrian. Ccvsar. 

Now are not these great considerations? and yet from what 
meanness do they spring, even the germiferous tissue of the 



40 THE FEMALE. 

female ! It is from her stroma that issues the generic as well 
as the genetic force! What a wondrous law! what a won- 
drous power is that which maintains each genus and species pure 
and unalloyed as when it issued from the Creator's hand ! So 
strange, so powerful, that each of them is set, as it were, within a 
magic ring, out of whose charmed round it can never stray; so 
that no wild and horrid passion, no brutal lust, no insane desire 
can break, much less change or abrogate the law that set forth 
the primordial models, "each after his kind," of the species of 
the globe. For notwithstanding the countless myriads of genera- 
tions that from the remotest ages have reproduced individuals 
more numerous than the sands of the shore or the stars in the 
firmament, each blade of grass still obedient to its generic law, 
still imitates exactly its primitive pattern; and every elephant or 
worm ; every eagle that soars to the sun, or sparrow that chirps 
in the hedge ; every man, and every woman go steadily, like the 
current of a river, down Time's flowing stream, ever ending, ever 
beginning, always changing, yet immutably the same ! 

I repeat it, the generic power is launched from the ovarian 
stroma : that is the sole animal concrete that is capable of produc- 
ing yelk matter. Yelk matter is germinal or generic matter; I 
should rather say reproductive matter. The male tissues are no- 
where endowed with the power of this yelk production, and the 
sole elaboration of the stroma of ovaries is germ-elaboration. See, 
then, in this unobvious, apparently vile lump of animal texture, 
in the inner court of the temple of the body, — the ark that con- 
tains the law, which keeps the genera unmixed, from age to age. 
How can you study this subject sufficiently? 

But let us pass to other views. Let us go to look upon wo- 
man in the phases of her intellectual nature. If we scan her 
position amidst the ornate circles of a Christian civilization, it is 
easy to perceive that her intellectual force is different from that 
of her master and lord. I say her master and lord ; and it is true 
to say so, since even in that society she is still in a manner in 
bonds ; and the manacles of custom, of politics, or of bienseance 
not yet struck from her hands. She has nowhere been admitted 
to the political rights, franchises and powers that man arrogates 
to men alone. The Crown, when it rests on the brow of a wo- 
man, is always a political accident, grievous and deprecable: 
and even then, where woman reigns, man governs, 



THE FEMALE, 41 

The great administrative faculties are not hers. She plans no 
sublime campaigns, leads no armies to battle, nor fleets to vic- 
tory. The Forum is no theatre for her silver voice, full of ten- 
derness and sensibility. She discerns not the courses of the 
planets. Orion with his belt, and Arcturus with his suns are 
naught to her but pretty baubles set up in the sky. She guides 
no ship through night and tempest across the trackless sea to 
some far-off haven half round the world. She composes no Iliad, 
no iEneid. The strength of Milton's poetic vision was far be- 
yond her fine and delicate perceptions. She would have been 
affrighted at the idea of that fiery sea on whose flaming billows 
Satan, 

"With head uplift above the wave, and eyes 

That sparkling blazed 

extended long and large, 
Lay floating many a rood : in bulk as huge 
As whom the fables name of monstrous size ; 

■ or that sea-beast 

Leviathan, which God of all his works 
Created hugest that swim the ocean stream.'' 

Do you think that a woman, who can produce a race and 
modify the whole fabric of society, could have developed, in the 
tender soil of her intellect, the strong idea of a Hamlet, or a Mac- 
beth? Could her voice, like the accents of Hortensius, or Tully, 
or Chatham's, or Burke's, command the bent ear of listening 
senates, or move like a tornado the agitated masses of a peo- 
ple tossed in the tempest of its own vehemence; and then, like 
a gentle west wind, soothe and calm them down again by the 
influences of its reasoning and prayerful suasion ? 

" Ille regit dictis animos, et pectora mulcet/' 

ifoSTEID, I. 

Such is not woman's province, nature, power, or mission. 
She reigns in the heart ; her seat and throne are by the hearth- 
stone. — The household altar is her place of worship and service. 
— The Forum is too angry for her. — The Curia is too grave and 
high, and the Commitia too boisterous and rude. — Home is her 
place, except when, like the star of day, she deigns to issue forth 
to the world, to exhibit her beauty and her grace, and to scatter 
her smiles upon all that are worthy to receive so rich a boon — 
and then she goes back to her home, like as the sun sinks in the 



42 THE FEMALE. 

west, and the memory of her presence is like the sun-light that 
lingers long behind a bright departed day. 

Her voice is not for brawling. Its tender tones are for sooth- 
ings and caressings. The sweetest lute is in her vocal organs ; 
and with its music she stifles the passion, assuages the rage of 
her master, and reduces back to the gentlest flowing, the furious 
tide that boils in his veins. It is by the mere contrast of her 
gentleness, her docility, her submissiveness and patience, that 
she makes herself the queen and the arbitress of the fate of whom 
she loves, and whose best rewards for the pains, hazards and 
toils of existence, are ever to be found within the narrow circle 
of her domestic reign. 

It is true, that we meet in the pages of History and Biography, 
the relations of strange phenomena in the lives and actions of 
certain women. There are Julias and Messalinas, that are mon- 
sters. There is even somewhat questionable in the nature of 
such ladies as Elizabeth, or Mary of Medici. — We have the male 
powers of a Dacier and a Stael. We find the gentle and femi- 
nine Hemans sometimes bursting forth with a wild, impetuous 
and martial enthusiasm. Yet these are exceptions, and not rules, 
that fill us with surprise, as of things out of, or beyond the com- 
mon course of nature. 

The bibliographical lists are full of the prettynesses of the ladies. 
— No Mecanique Celeste — no Principia — no Treatise de Senec- 
tute — no annals of Tacitus ; but canzonetti, fairy tales, stories of 
the heart, Mysteries of Udolpho, and Coelebs in Search of a Wife. 
Such are their w r orks. So that it is easy, by a slight glance at 
history, and by the facts that surround us, to conclude that the 
intellectual and moral force of the female are different from those 
of the stronger or ruder sex. 

Who could imagine such an intellectual fairy as Felicia He- 
mans joining a charging squadron of crusading chivalry, with 
Godfrey de Bouillon, or Cceur de Lion, and glorying in the com- 
mingling of the spears? Yet, though timid herself, her very ten- 
derness gives her the keenest perception of the nature of courage, 
and the deepest sympathy with the feelings of her gallant knight. 

See, gentlemen, in the following lines by Mrs. Hemans, her 
touching sympathy with a captive Crusader in some lofty Pagan 
tower, perched above a deep craggy wady in Palestine. 

Worn and wearied with a long and lone captivity, his valiant 



THE FEMALE. 43 

heart, though broken, still pants, in its solitude and hopelessness, 
for the freedom and action of the field. Suddenly he starts at the 
wild scream of a bugle ! 

'Twas a trumpet's pealing sound ! 

And the Knight look'd down from the Paynim tower 

As a Christian host, in its pride and power, 

Through the pass beneath him wound. 

Cease awhile, Clarion — Clarion loud and shrill — 

Cease ; let them hear the Captive's voice. — Be still, be still. 

I knew 'twas a trumpet's note ; 
And I see my brethren's lances gleam, 
And their pennons wave by the mountain stream. 
And their plumes on the glad wind float. 
Cease awhile, &c. 

I am here in my heavy chain ! 
And I look on the torrent sweeping by, 
And an eagle rushing to the sky, 
And a host to its battle plain ! 
Cease awhile, &c. 

Must I pine in my fetters here 
With the wild wave's foam 
And the free-bird's flight, 
And the tall spears glancing in my sight, 
And the trumpet in my ear 1 
Cease awhile, Clarion, &c. &c. 

Now, for my part, I cannot but see in these verses of that most 
sweet poetess, proofs of her liveliest sensibility to both the nature 
and the intenseness of those male passions, which, however they 
may be fitted to enkindle her admiration, and enslave her heart, 
as forming a perfect antithesis to her own gentle nature, would, 
as existing in her own breast, demoralize and deform it. 

The military pennons and plumes floating on the glad wind, 
and the tall spears glancing in her mental sight, are not for her 
to wear or wield. But she may well glory in the hero who is 
both able to wield and to wear them. 

As to the more strictly moral attributes and propensities of the 
female, what are the facts ? Is not her heart, in general, the seat 
of tenderer and gentler emotions than those of her mate ? Her 
susceptible soul is acutely alive to the human charities and trem- 
bling sympathies that spring spontaneously in the delicate inner- 
vations of her feminine constitution. She cannot unmoved look 
on scenes of woe. 



44 THE FEMALE. 

She melts at the spectacle of human distress — a maiden shelter- 
ing a wounded dove in her bosom is an eidolon of the sex. 

Mungo Park in the Sahara, and Ledyard among the wildest 
Samoiedes, always received good, and not evil entreaty at the 
hands of women, whose husbands had hearts like the nether mill- 
stone. 

Notwithstanding the poet has characterized her as being, 

" in our hours of ease, 
Uncertain, coy, and hard to please, 
And variable as the shade 
By the light trembling aspen made," 

she is faithful and true. She follows the fortunes of her mate, 
who has gained her affections. Yea, she adheres to the promise 
at the altar, which was for better for worse, for richer for poorer, 
in sickness and health — even unto death ; so that the same 
rhymer apostrophises her with 

"When pain and anguish wring tbe brow 
A ministering angel thou !" 

What a beautiful picture is that engraving of the " Intem- 
perate!" which you see everywhere in the print shops? What 
touching, what immortal fidelity is depicted by the artist in the 
face of that woman! A face beautiful in its expression of resig- 
nation, and of pride in her own faithfulness and truthfulness, as 
she bears on her bosom the youngest child, while she leads a sick 
boy by the hand, and is clutched by a timid older girl, all of them 
barefooted, houseless, hopeless, homeless, for they leave behind 
in the distance, the pretty cottage where they were born, to pur- 
sue, along a rugged way, the uncertain, drunken footsteps of the 
husband and the father, who leads them miserable far away, 
deserting the homestead she had brought as her dower, in that 
blessed morn when in the village church she gave herself away 
for him. Now here is her reward! But she will cling to him 
until the death of the drunkard shall have broken the bond ; and 
after that, go weep on his discreditable grave, and forgive him 
too. Such pictures are from life. There are thousands of such. 

The female is naturally prone to be religious. Hers is a pious 
mind. Her confiding nature leads her more readily than men to 
accept the proffered grace of the Gospel. If an undevout astro- 
nomer is mad, what shall we say of an irreligious woman? See 



THE FEMALE. 45 

how the temples of the Christian worship are filled with women. 
They flock thither with their young children, and endeavor to 
implant in their souls the seeds of virtue and piety, to be reared 
in that pure soil and by their watchful nurture, into plants that 
shall blossom like the immortal amaranth among the stars. See 
then what and how great the influence that women exert on the 
morals of society, of whole nations, of the whole world : wherever 
there is a true civilization, woman reigns in society. It is not 
until she comes to sit beside him, in view of all the people, that 
man ceases to be barbarous; or semi-barbarous, and cruel, and 
ignorant. 

She spreads abroad the light of civilization and improvement 
as soon as she issues from the prison of the Harem, or Zenana, to 
live with him in the world. Who made us human? Whose 
w T ere the hands that led us to kneel down and whose the lips that 
taught our infant voices the earliest invocations to Heaven? Is 
it not so, that after the world and fortune have done their best, or 
their worst by us, w r e, in late years, and early, forget not those 
pious mothers, who so steadfastly strove to bias our young minds 
in favor of whatsoever is true, whatsoever is pure, whatsoever is 
of good report!! How can w T e forget the rewards we received at 
her hands for all our good, and the gentle, and sometimes tearful 
reproachings of our evil inclinations and practices ? She was not 
only our teacher and pattern, but our companion and playfellow, 
for, of a truth, she was of a child-like temper — and that was the 
secret of the bond that united us so long and so closely. Hear 
what an eloquent Frenchman says of her : 

" Source feconde et sacree de la vie, la mere est la creature la plus respectable 
de la nature ; c'est d'elle que decoulent les generations sur la terre ; c'est Eve ou 
1'etre vivifiant, qui nous rechauffe dans son sein, qui nous allaite de ses mam- 
melles, nous recueille entre ses bras et protege notre enfance dans le giron de son 
inepuisable tendresse. Femme ! mere! honneur de la creation ! quels hommages 
eternels ne vous sont pas dus dans tout Funivers ?" 

Virex. — La Femme. 

The male is less versatile than the woman. His mission is 
more adventurous and dangerous. He enters on the path of am- 
bition, that dark and dangerous, or broad and shining road. 

He pursues the devious track of politics with a resolute will ; 
reaching ever onwards to the possession of fame and patronage, 
and rank and wealth. 



46 THE FEMALE. 

She sits at home, to adorn the tent or the cottage with wreaths 
of flowers; or to guide the tendrils that give shade to his bower. 
She plies the busy loom — and the sweet sounds of her singing — 
how often have I listened as they accompany the hum and buzz 
of her wheel, as she gracefully advances and retires by turns, 
forming the threads about to be woven into garments for her hus- 
band or child! Her nimble fingers, all day long, ply the shining 
needle, to fashion the robe for her spouse — or to arrange the more 
elegant embellishments of her person, that they may engage his 
admiration, and augment the flame of his love. For woman, 
man's love is the moving spring of all her actions. This is at the 
foundation even of her vanity. Lais herself is said to have sacri- 
ficed even her rage for wealth, at times, to the gratification of her 
vanity; and the lioness tearing a ram to pieces, which was sculp- 
tured upon her tomb, was the emblem of her insatiable avarice. 
Yet Lais lived more for love than for gain. 

"What say you of the fortitude of woman ? She bears the evils 
of life without repining or complaining against the providence of 
God. Is she evil entreated, prevented, injured? That which 
sets a man on fire with an insane rage, kindles in her bosom, 
perhaps, only a virtuous feeling of indignation. She bears the 
greater crosses. How beautifully does Shakspeare say so in the 
words, 

" She never told her love, 
But let Concealment, like a worm i' the bud, 
Prey on her damask cheek ; 
And sate, like Patience on a monument, 
Smiling at grief." 

She dies a willing martyr for religion, for country — for her 
children. 

Who can number the Lucretias and Portias ? How many are 
like the charming Roland? Think of the calm features of Char- 
lotte Corday! 

Women possess a peculiar trait — it is modesty — and is one of 
the most charming of their attributes ; springing probably from 
their natural timidity and sense of dependence. All rude, bois- 
terous, and immodest speech or action unsexes and disgraces 
her. This modesty is one of the strongest of her attractions ; and 
she sometimes, perhaps, affects to possess it for the purpose of 
riveting her chains on the conqueror man. 



THE FEMALE. 47 

Malo me Galatea petit, lasciva puella, 
Et fugit ad salices et se cupit ante videri. 

The attribute of modesty certainly lends the most powerful 
aid to the charms of a woman. It is one of the qualities given to 
her in order to be a strong fence for her children ; it binds her to 
the domestic altar — her children could not but endure damage 
and loss, should she leave them at home to plunge into the torrent 
of public affairs, or mingle freely with the distracting world ! 
Her modesty, gentleness and timidity assimilate her to the cha- 
racters of children, whose best playfellow, nurse, and instruc- 
tress she is. Come out from the world, and be separate from it, 
is peculiarly a command for her. 

There is in the Museo Pio-Clementino, at Rome, an antique 
statue, which the learned Visconti asserts to be a statue of Mo- 
desty; and, as I am informed, is among the most beautiful of the 
works of ancient art now remaining in the world. It is com- 
pletely clothed from head to foot, and veiled. It seems to me 
that such a w r ork is proof enough of the ancient admiration of the 
quality in question ; for the artist who could produce, and the 
people who could appreciate such an exquisite specimen of taste 
and right feeling, must have had a keen perception of the charm. 

By her physical form and proportion, she is still more trench- 
antly divided from the male. Look at two statues, male and 
female. Take the Venus de Medici as the consummate expo- 
sition — the very eidolon of the female form, just as Praxiteles in 
the greatest verve, fervor and enthusiasm of his genius, and he 
alone of all mankind, could conceive the idea of the Queen of the 
Loves. 

Compare her with the Apollo of the Belvidere — she has a head 
almost too small for intellect but just big enough for love. His 
magnificent forehead, calm as Heaven, and almost as high as it, 
rises above those eyes that are following the shaft he has sped 
with his clanging silver bow. 

The front of Jove himself, 

An eye like Mars, to threaten and command ; 

A station, like a feathered Mercury, new-lighted on 

Some Heaven-kissing hill. 

Her thorax seems built as the sanctuary of that beautiful bosom, 
whence is destined to flow the sweet nutriment of the winged 
boy. 



48 THE FEMALE. 

His vast chest is for breathing, and for eloquence and com- 
mand. From its capacious stores of oxygen he draws the ele- 
ments of the most strenuous, the most protracted exertion. He 
breathes deep, that he may ascend the highest hills and the 
sharpest crags in pursuit of his game or his prey, and that his 
loud harmonious voice may command his armies in the midst of 
the conflict — or sway the forum with its tones. Like Virgil's 
wild horse — he is equal to the longest career — nothing can stay 
him in his race. 

Non Seopuli. rupesque cavae, atque objecta retardant 
Flumina, coiireptos unda torquentia montes. — Georg. III. 

See his loins how they are narrowed down, as they approach 
the hips, that he may balance himself, as it were, on the point 
of an inverted cone, ready for the promptest motion. His pelvis 
contains no variable organs, requiring ample space for extraor- 
dinary developments ; but its depth and solidity afford origin and 
insertion to the powerful muscles, by whose immense strength he 
can act well in the wild, rude, and adventurous life to which he 
is ordained. 

The cone, on the other hand, is reversed in the female. The 
apex is above, and the base is at the hips. It is within that 
bony cell that are hidden those miraculous organs, that out of 
nothing, can evolve the wondrous work of reproduction. Her 
pelvis is broad and shallow, lighter in substance, its excavation 
ampler, and' its pubic arch round or Roman ; while his is Gothic 
or lanceolate. From under this arch a child could not go; the 
other gives it easy utterance. The organs of the male are perma- 
nent — hers are mutable. The uterus — no bigger than my thumb 
■ — comes in gestation to be twelve inches high and nine in width. 
Its invisible vessels and nerves come to be great cords and tubes, 
and its uncognoscible muscles acquire a force to rend itself in 
pieces in its rage, and, what seems still more miraculous, to ex- 
pel a full-grown foetus from its parietes, against the enormous 
resistance of flesh and bone. She is a germiparous and vitelli- 
ferous creature. She — the female — possesses that strange com- 
pound or concrete which you call stroma, ovarian stroma, of 
which I already have spoken, but must again speak. Now that 
stroma lives by the blood it receives out of a common endangium, 
and yet it has a nerve which enables it to convert that blood into 
vitellus or yelk. The perpetuation of races and germs depends on 



THE FEMALE. 49 

the elimination of that matter. There is no animal germ without 
it — so that an organ so small, so unobvious, is endued with the 
vast responsibility of keeping up the living scheme of the world 
— with its moralities — its lives — its actions — its trial — which, 
were it to cease, there would be left no flowers to bloom, no in- 
sects to sport in the evening beam, no choral song of birds, no 
lowing of cattle, no bleating of flocks, nor voices of men to thank 
and praise and acknowledge the author of every good and every 
perfect gift. 

Think of that, gentlemen. Think of that great power — and 
ask your own judgments whether such an organ can be of little 
influence on the constitution of the woman ; whether she was not 
made, in order that it should be made, and whether it may not 
on occasion, become a disturbing radiator in her economy, and 
how much. You will answer yes, if you know that her ovary is 
her sex — and that she is peculiar because of, and in order that 
she might have this great, this dominant organ concealed within 
the recesses of her body. 

Men cannot suffer the same pains as women. What do you 
call the pain of parturition ? There is no name for it but Agony. 

Why does she love her child more than its father does. Why, 
he grew to her; he was perhaps an acinus cast out of her stroma, 
and after drawing his blood from her own blood, he drank life at 
the living well of her bosom, and character from her monitions 
and example. What were Cornelia's jewels ? Who was Wash- 
ington's mother ? 

What do we owe her? — life, peace, liberty, social order. She 
built up this great frame of society in civilization. It is to her 
we are indebted for our 

"Placidam sub liberate quietem." 

Christianity is propagated by her domestic influence. Th'e 
loom is her work, and the tapestried walls are of her imagining. 
Were it not for her we were this day clothed in sheep skins and 
goat skins, and should lie down in dens and caves. It is for her 
that the looms of Cashmere, the silks of China, the gauzes of 
Hindustan, the mousselines of Lyons, the laces of Belgium and 
England are formed; the carpets of Ispahan and Dresden, Cor- 
nelius' blazing chandelier, all the riches displayed by Levy and 
4 



50 THE FEMALE. 

Baily are for her. Everything that man is and hath, except his 
brute force and brutal inclinations — are of her, and for her. 

See her gliding down the Cydnus in her stately barge, with its 
silken sails and costly equipage, and the great Triumvir at her 
feet, who thought the world well lost for her love, and gave up 
the world to lie there. 

Look at her in the regal halls of Windsor, waving her golden 
sceptre around the globe over dominions of hers, on which the 
sun is never set for all. Drive her out, and all her sex with her, 
to the primitive rudeness of her nature, and leave man alone, and 
what should move him afterwards to do more than is done by the 
lions and tigers, who follow their instinct, and who are less cruel 
than he by nature, since he reasons in his evil, while they are 
only instinctively monstrous ! 

Study the nature of woman, young gentlemen, follow out all 
the psychological and physical transformations which her sex 
produces. What is her erotic state? what the Protean manifest- 
ations of the Life-force developed by a reproductive irritation 
which you call Hysteria. 

Take Martin Barry's microscope, and BischofPs History of 
Development, and study the myriad germ points that are buried 
in the depths of her stroma. 

I have already placed in your hands the key that unlocks all the 
secret details of her mensual phenomena, and not hers only, but 
those of all that reproduce, both of the animal and vegetable 
kingdoms of nature. 

It were an endless task to undertake the protraiture of all the 
characteristics of the sex, as exhibited in their intellectual and 
moral aspects. 

I have made the foregoing slight indications of them, with the 
purpose of turning your thoughts in that direction; fori believe 
the contemplation of such subjects is extremely useful to the prac- ■ 
titioner of physic, and especially so to those that have design to 
engage themselves in the business connected with the obstetric 
art and practice. I shall not deem it necessary now to do more 
than merely hint at the potent influence which must be exerted 
upon the pathological tendencies and states of the female, by the 
constitution of her organs, and, indeed, by the more delicate, 
gracile and impressionable nature of her whole economy. I say I 
shall merely hint at the subject in this letter; for as much as the 



THE FEMALE. 51 

whole series is relative to these effects, I shall treat of them herein 
in extenso. 

Appreciating as I do, at the highest possible rate, the influence 
of the gentler sex upon the character and action of the male, I 
cannot but see in that influence the cause of a major part of the 
happiness now enjoyed by mankind in civilized, or, to speak 
more exactly, in Christian lands. It is true that, during the 
great glory of the Roman empire, manners, luxury, pomp, had 
attained to a high perfection ; but it is equally true, that the 
social and domestic position of the women was even there ele- 
vated, although not to a station so coequal as that to which she 
has attained in our own age. Petulanter facimus, si matrem- 
familias, secus, quam matronarum sanctitas postulat nominamus, 
— is the saying of Cicero. 

When, upon the dismemberment of the Roman empire, and the 
darkness that was consequent to the descent of the barbarians 
into western and southern Europe, society seemed to have lost 
all its security ; and when brute personal force appeared to be at 
the foundation of all administration, as well as of all domestic 
security, the sex came forth again, and by troubadour and 
knight, w T hom she created and moved, brought her human- 
izing hand to bear upon, and to recompose the shattered frame 
of society. The virelay and the tale of the troubadour, and the 
scarf of the knight, were worthless but as sanctioned by her 
smile of approbation. The Tales of Boccacio, the old Romances, 
the illuminated missals and hours, led by degrees up to the search 
for a higher literature and a truer learning; so that at the breaking 
forth of the love of letters in Europe, the way was already pre- 
pared for their reception and just appreciation. Education, de- 
cency, what is understood by good breeding, laws of society, all 
these take much of their complexion and most of their beneficence 
from the sex, who thus, while disfranchised as it were, by the 
political constitution of the world, are yet, in fact, the secret 
promoters and moving powers by which it is made both pro- 
gressive and improving. 

In speaking thus of the influence of women on society, I do not 
wish to disparage that of religion, of which they are justly to be 
viewed as the promoters ; nor would I lessen the sense of grati- 
tude due to the wise philosophers, the good legislators, the ardent 
philanthropists, to whom we owe an impayable debt of reverence 



52 THE FEMALE. 

and praise. I am far from desiring to look on woman as the 
race — I contend that though she is unlike man in her fleshly 
nature, and different from him in her intellectual nature, yet she 
is a great and predominant force in the world ; physically weaker, 
yet not less noble ; restrained of power, yet the cause and reward 
of his efforts — requiring his protection, his homage, his love, yet 
repaying him in the perpetual provocation she offers to noble 
endeavor; more than compensating him for support, in the rear- 
ing of his offspring, and by the humanizing, softening, meliorat- 
ing influence which she carries into his public as well as his 
domestic life. 

But why should I attempt, or why should I have attempted a 
theme too great for a volume, and far beyond my abilities. You 
see how I have failed. It requires the eloquence of a Roussel 
and the learning of a Virey, to present even a sketch of a topic 
so vast, so interesting, so closely related to whatever may be 
called happiness, whether domestic, or social, or political. 

I hope you will study this subject better than I have done, or 
can do. 

I do not believe in a physician who knows only calomel and 
rhubarb. I would have you fill your souls with knowledge ; I 
would have you bathe in it as in an ocean. Were I young again, 
and could I appreciate as I now in some degree begin to do, the 
beauties of learning, I could not cast away, as I have done, a 
half century of time, but I would grow pale by the reflection of 
the midnight lamp, and I would never be satiated until my soul 
were satisfied with the fulness of knowledge. For what are we 
in the general but erring and curious inquirers ? and, does not 
the most highly cultivated intelligence to be found among men, 
leave them at last, even the most gifted among them, blind, grop- 
ing, feeble worms of the dust? What should be our motto and 
our cry, from the lowness of the human nature in which we lie 
groveling? — Excelsior! Excelsior! C. D. M. 



SEXUAL ORGANS. 53 



LETTER V. 

SEXUAL ORGANS. 

Gentlemen: — In my Letters I have set before you some gene- 
ral ideas on the nature of sex in the female ; and have also pointed 
out some of the more distinctive characteristics of that best half 
of our race. In this letter, I shall speak to you of the reproductive 
organs; begging you to accompany me in the disagreeable task 
of this investigation with minds purified by the love of truth, and 
by that decent self-respect, which ought to guard every physician 
when he comes to study, as a part of his professional obligations, 
this department of anatomy; a department we cannot omit to 
learn, without leaving ourselves incompetent to the safe discharge 
of many important medical and chirurgical duties ; and which we 
cannot study without feeling that we are engaged in inquiries that 
ought not to be exposed to the public gaze. 

Instead of treating in this letter, of the private parts in question, 
I might perhaps as well have referred you to the anatomical treat- 
ises already published ; but, by so doing I feel that I should leave 
this volume less complete than it ought to be. 

In a recent report of testimony given before one of our courts 
of justice, where a person was in question for having published 
an obscene book, pretending to be a medical work, a witness 
characterized it as "fit to be seen only in a Doctor's shop." 

Let us take a lesson from this undesigned reproof of the medi- 
cal faculty; and while we acknowledge that our ministry calls 
upon us to know all that can be learned as to the anatomy and 
physiology of the reproductive organs, let us admit also that it 
behoves us out of a feeling of self-respect, and respect to our 
calling, to treat these subjects with all decency, and with a just 
deference to our friends not of the profession; who, having no 
claims to acquire the knowledge we are compelled to obtain, 
must not be offended by any unavoidable indelicacy of expression 
in our writings. Such persons being to us entirely esoterical, ought 
not to suffer themselves to pry into those particular mysteries of 



54 SEXUAL ORGANS. 

the medical profession, which it is better for them not to learn 
than to know. If they look into our books and blush, they are 
like eaves-droppers, who generally hear no good of themselves. 
As for us, let us remember that the President of the Board of 
Trustees, who, in the name, and by authority of the State of 
Pennsylvania, admitted you to the rank and quality of Doctors in 
Medicine, declared you vested with the powers exercendi, docendi 
et scribendi, ubi ritevocatifueritis; and that this commission allows 
us a great privilege of discussion; which being needful for our 
art and the security of the people, is decent and proper in our 
hands, but vile and contra bonos mores in the hands of other people. 
Fantoni, as cited by Dr. Asdrubali, in the Trattato Generale 
di Ostetricia, &c, p. 68, t. 1., says, " Honesta quantum potero, 
muliebria examinando; honeste, inquam si potero; nam fieri vix 
posse puto, ut honestis appellationibus res vulgo obscsenas de- 
signamus, quae facile pudicas aures offendunt. Sed vobis nullus 
sit pudor integris auribus ea excipere quse divina sapientia creare 
non erubuit," &c. 

The reproductive organs of the female are external, and inter- 
nal. The former being situated upon the outer face of the pelvis, 
and the latter concealed within its bony cavity. 

A sense of modesty induced the ancients to give the denomina- 
tion of pudenda to the external or visible privities of the female ; 
and this word, which is a plural noun, applies to the whole of the 
external genitalia. 

The pudenda, therefore, comprise the mons veneris ; the labia 
externa, also called labia majora; the labia interna or minora, 
called also nymphas ; the clitoris ; the prseputium clitoridis ; the 
vestibulum; the os magnum; the caruncuke; the hymen; the 
fossa navicularis; the fourchette, and the perineum. 

The internal genitals are the vagina, or vulvo-uterine canal, 
as the Frenchmen call it; the uterus or womb ; the Fallopian 
tubes; the ovaries ; the round ligaments, and the broad ligaments. 

The word vulva applies to the sexual fissure, rima, or sulcus, 
that is observed between the two opposite labia majora. 

Now, as to the mons veneris (le Penil,) it is an elevated portion 
of skin, that is lifted above the general level of the lower part of 
the belly, partly because it is on the share-bone or os pubis, and 
partly because it is underlaid by a considerable quantity of adi- 
pose tissue filled with fat. 



MONS VENERIS. 55 

This part of the skin is of a darker color than that which is 
above and about it ; for it contains a portion of pigmentary mem- 
brane which deposits on the exterior surface of its corpus rnuco- 
sum,the same sort of dark matter as is known to color the axilla, 
the aureole of the mamma, the perineum, &c. It is also covered 
abundantly with hair, w T hich begins to make its appearance under 
the critical efforts of the constitution when those efforts are being- 
employed to convert the creature from childhood to puberty ; — or, 
in other words, when she is about obtaining such a degree of 
development as may consist with the power of germ-production. 
It is not unworthy of your observation, that when the power of 
germ-production is lost at the change of life, that of producing the 
pudendal hair is diminished very sensibly, and in old age, not 
unfrequently goes to the extent of a complete depilation. 

Women also, who from feebler health, cease to bear children, 
as they advance in age, but who have not w T holly lost the faculty 
of germ-production, often find that the pudendal hairs are less- 
ened in abundance during the suspension of the child-bearing 
faculty ; and that the crop is greatly increased as soon as they 
find themselves again pregnant after many years have passed 
since any former gestation of theirs. This I have learned from 
several cases observed and inquired of in my clinical experience, 
for I have many times had charge of labors in women, who being as 
it is called getting old, and not bearing children for eight, ten or 
twelve years, w r ere yet surprised and vexed to find themselves so 
wonderfully young again. 

As to the disorders to which the structure called the -mons 
veneris is liable ; you will be sensible that they must be of the 
nature of the exanthematic and phlegmonous inflammations, con- 
tusions, and wounds ; and that such affections have not and can- 
not have any special relation to what is properly called midwifery. 
Perhaps, indeed, we may except some rare samples of pain, 
neuralgia or inflammation of the textures connected with strains, 
or violence done to the symphysis pubis ; either by the protracted 
influence of continued pressure and weight on the pubes by a 
heavy womb ; or by injurious tension and even disruption of the 
symphysis or of the bone, under the transit of an overgrown 
foetus, or a badly managed forceps operation ; where great violence 
is sometimes done to the bony structures, either by the power of 
the womb in its expulsive efforts, forcing too large a child 



56 RELAXED SYMPHYSIS PUBIS. 

through too small a pelvis ; or where, by the additional power 
of the forceps, such a child is drawn through such a pelvis, the 
articulation of the pubis, which lies underneath the mons vene- 
ris, becoming so strained as to inflame after the labor is over : 
or the bone itself may be broken asunder, as in some instances 
related by Madame Lachapelle in her admirable Treatise on Mid- 
wifery. 

In any such cases, where pain is felt in the lower part of the 
mons, as I have heard many persons complain, it appears obvi- 
ous that the same chirurgical treatment ought to be adopted as 
is known to be most suitable to the articular maladies in general. 

Professor Mutter has doubtless taught you that, in the treat- 
ment of articular inflammations, rest is of the primest force ; and 
that in the movable joints, when inflamed, the splint is the first 
and greatest of remedies. Hence, in the instances where your 
patients after childbirth, shall complain of pain in the mons, in 
walking, or in turning in bed, you ought to direct your attention to 
the condition of the symphysis of the pubis. 

I have met with many instances wherein the ligaments that 
bind the ossa pubis together have become so relaxed, probably 
under the infiltrative influences of pressure and tension, continu- 
ally exerted by the gravid womb, as to allow of a very per- 
ceptible play of the opposite ends of the ossa pubis upon one 
another; the right pubis moving upwards when the woman stood 
upon the right foot, and the left one rising above it again as she 
stood upon the left foot. I leave you to imagine the pain, the 
discomfort, the uncertainty and the feebleness of gait, attending 
so large, or even the least motion of this important joint. You 
fully know that the pubal bones cannot pass and repass each 
other, without, in some degree, disturbing the repose of the sacro- 
iliac junctions ; and I have shown you what sort of a cartilage 
that is, that we used to study under the denomination of the 
auricular cartilage of the sacrum and ileum. A cartilage so firm 
and resisting as that, could not become the subject of motion 
without the greatest inconvenience. It could not be treated by 
means of internal medicines ; nor could any counter-irritants, lini- 
ments, lotions, or plasters, or ointments, have a very useful effect 
in the treatment. 

Hence, you perceive, my friends, that, for your patients com- 
plaining of such movableness of the joint, there is but one chi- 



RELAXED SYMPHYSIS PUBIS. 57 

rurgical principle ; and that is, the joint must be allowed to rest. 
She must not make it move by walking about — for she can never 
transfer the w T eight of her body from one foot to the other, without 
transferring it from one acetabulum to the other; and you remem- 
ber that the pubis owns one-fifth of the acetabulum, and you 
ought to know, that an inflamed joint is nearly as little apt to be 
cured while motion is allowed in it, as a broken bone. They 
equally demand the use of the splint. This is the treatment sug- 
gested and used for half a century by our illustrious compatriot 
Dr. Physic. In Europe, it is becoming understood within a few 
years past. 

I have tried various bandages, springs, and compresses, to 
relieve certain of my patients thus affected; but such bandages 
are intolerable, because they cannot be kept in adjustment. Some 
women have soon spontaneously recovered by means of rest, 
which permits the joint again to become firm; while others have 
continued to suffer more or less through successive pregnancies. — 
Rest is the cure. 

I will not say, that where the disturbance of the joint has 
caused an attack of inflammatory congestion, rest alone is indi- 
cated — for, in such a state of things the patient might very rea- 
sonably expect that you should seek to relieve her, further, by 
means of leeches; by counter-irritant applications; by stupes and 
cataplasms, and by anodyne liniments; for the selection of w T hich 
remedies in particular, I must refer you to the indications of the 
special case and time — as well as to your memory, for what Pro- 
fessor Mutter has counselled on such topics. These remedies are 
not dependable. — Rest is the cure. 

I hope you will come to the conclusion, that wherever the 
symphyses of the pelvis are found loose and relaxed after gesta- 
tion, that effect has been produced by a maladive condition. I 
am fully of Dr. De wees' opinion on this point, and he used to 
scout at the notion of the bones naturally yielding in order to let 
the child escape more easily. 

Dr. Moreau of Paris, whose excellent work on midwifery is in 
the hands of many of you, seems to think that the relaxation of 
the ligaments of the pelvis is not an unusual or unhealthful occur- 
rence; his remarks on the subject are at page 46, torn. i. I 
should be glad if you w 7 ould read attentively his relation of a case 
at page 47, as well as a most interesting one at page 51. The 



58 THE SETON IN PUBAL PAINS. 

perusal of them would serve to show you how to act under similar 
circumstances. My own experience has not given me any op- 
portunity to observe such great disorders as he describes in his 
patients. 

When I was in the city of Brussels, in the month of June 1845, 
I paid a visit to the magnificent Hospital of St. John, in that city. 
The medical officer on duty that day, was Dr. Grauiex, whose 
name is pronounced Gro. While accompanying him through the 
wards, and observing his methods of diagnosis, and of therapeu- 
tical direction, we arrived at the bedside of a very fine looking 
young woman, about 22 years of age, who did not look at all in 
bad health. I found she had been for a considerable length of time 
under treatment for a catarrhus vesicae, and that she had made no 
progress towards a cure. The frequent micturition was painful 
and annoying. Dr. Grauiex, after carefully examining the region 
of the bladder by palpation, took out a seton-needle already 
armed, and in a moment he passed a very long seton from side to 
side, near the upper edge or limit of the mons veneris, to the 
great chagrin and vexation of the young girl. But Dr. Grauiex 
was master in the case, and she was obliged to submit. I told 
him it was the first example I had seen of such a treatment of 
the troublesome disorder in question, when he rejoined that he 
regarded it as the most efficacious he had known ; and that he 
had learned it at Paris, in the service of the illustrious surgeon 
the Baron Dupuytren. Dr. Grauiex seemed to me, to feel quite 
sure that his operation would cure the patient; but, as I very 
soon afterwards left the city, I am not able to state the result. I 
should think, from the opportunity I had of seeing Dr. Grauiex, 
and conversing with him, that his opinions on any chirurgical or 
medical subject are deserving of great respect. 

I have related this case, in order that you may, if occasion 
should arise in your practice, resort to it for the treatment of some 
of the more rebellious forms of cystic irritation and inflammation, 
as well perhaps, as for that of certain conditions of uterine func- 
tion that do not yield to gentler modes ; and I can suppose that, 
where the symphysis pubis has been injured in gestation or labor, 
leaving a chronical inflammatory state of the junction, you could 
hardly adopt a safer or surer remedy than this of Dr. Grauiex. 
It may seem out of place in this letter, but I trust, that whether 



VULVA LABIA PUDENDORUM. 59 

apropos or not, you will find it apropos in the chronic maladies 
of the parts crowned by the mons veneris. 

I am not aware that the seton has been thus employed in this 
quarter by any of my friends. 

Let us now proceed with our inquiries as to the other portions 
of the pudenda; and we shall find that the next in order is the 
part called the labia, the labia externa, or labia majora. They 
are called by Felix Plater, in his Treatise de Partibus Mulierunz 
Generationi Dicatis, by the name of Colles, seu monticuli. The 
Greeks called them xtl-ho^. Krauss, in his Lexicon, says that the 
Latin labium or labrum, is probably from the Greek juxj3«. The 
German is schaamlefzen, the French grandeslevres, the Italian 
grandi labbra pudende. 

In the young embryo, the whole body is open in front, and all 
the organs and viscera quite uncovered ; but, in the process of 
development, or embryogeny, the sides of the chest and belly, 
curving first forwards and then inwards, until their margins come 
into contact, they fuse, or unite or solder, the one to the other, 
and thus the thorax and abdomen become at last converted into 
closed cavities. 

In this process of union or fusion, a place is left for the entry 
and exit of the umbilical vessels ; the margin of the anus is left 
unfused; and the vulva, in like manner, refuses to allow the op- 
posing mucous surfaces of the labia to be soldered together. This 
open space then is the vulva, or the genital fissure, rima, sinus pudo- 
ris, &c, on the right of which is the right labium, and on the left, 
the left labium majus. The upper end of the fissure, where the 
derm is disparted, is the superior, and the lower one the inferior 
commissure of the vulva. The labia extend from the one to the 
other commissure. The exterior surface of the labia is skin, 
covered with hairs, that diminish in abundance from above down- 
wards. The interior aspect of the labia is a mucous tissue, which, 
in the young, is of a bright rose-color, but becomes of a darker 
and less sanguine hue, in persons of eighteen or twenty years old, 
and of a livid purpureous tint in the more aged. 

In fat persons, the labia are plump, or even turgid; in the 
macilent they grow lean, and possess not the firmness and 
solidity observable in the former sort of persons. I have ex- 
amined many hundreds of various ages. 

The structures contained within the dermal and the mucous 



60 LABIA. CEDEMA LABIORUM. 

laminae of the labia, is a cellular tela; and, as before remarked, 
is, in fat persons, filled with adipose cells. Of course, there is a 
good supply of blood-vessels and nerves and absorbents ; so that 
they are the not unfrequent seats of inflammations, that have a 
very great proneness to run into the suppurative termination. 

Inasmuch as the labia are also rather exposed to violence in 
falls, and blows ; as by kicks ; by falling astride of sticks and 
bars, &c, they present to us cases for counsel and treatment not 
unfrequently. 

These parts also are subjected to enormous elongation and 
pressure by the out-passing child, in parturition; so that they 
may be torn in the direction of their longitude, or fractured hori- 
zontally, or filled with vast deposits of blood, injected into their 
loose cellular laminae, from ruptures and wounds of the branches 
of the pudic vessel. 

In anasarca, and in the oedema gravidarum, the textures within 
the labia become greatly infiltrated ; and the dropsy of the labium 
renders it, at times, as large as a man's arm ; excessively tense, 
and exposed to attacks of erysipelatous inflammation, and to 
gangrene. 

Here, therefore, you will find a fruitful source of trouble to the 
female, and of opportunities to display your qualities as surgeon, 
physician and gentleman ; for I need not say, that without a just 
combination of all these qualities, you will never be acceptable 
as the medical counsel of those females, who may be so unhappy 
as to find themselves compelled to sue to you for help in so great 
a time of need and mortification. 

Whenever from an anasarcous condition, or from an oedema 
brought about by the pressure of the gravid womb on the ascend- 
ing currents of fluid, whether venous blood in the iliacs or cava, 
or of lymph in the absorbing vessels, you are complained to, of a 
painful or inconvenient tension of the labia externa, you will 
always, I suppose, feel it a duty to investigate the case for your 
own guidance, -and not confide in any description that may be 
proffered by the patient or by her nurse. 

There are many instances of swollen or rather infiltrated and 
distended labia, which require no special direction from you ; 
for, whenever, after an examination of the part, you can come to 
the conclusion that whatever fluid of infiltration it contains, can 
readily be pressed out of the cellular tela by the thrust of the 



(EDEMA LABIORUM. 61 

presentation against it, you will merely console your patient by 
assurance that no danger, and little inconvenience are to be ap- 
prehended from her situation. 

But, in certain other cases, in which labor is going on, or near 
at hand, you may deem the packing of fluid into the tissue to 
be so great, as to expose the woman to risk of rupture or lacera- 
tion of the labium, by the escaping head or buttock. Where you 
have any reason to fear that the labor may be protracted by the 
undue resistance of the labia, you may readily obviate the em- 
barrassment by making a few punctures on the inner face of the 
organ, with a slender lancet, the point of which should be carried 
merely through the surface into the cellular meshes. From these 
punctures the fluid soon escapes, whereupon the labium collapses 
again, and is more flaccid than before the tension came on. 

Dr. Dewees speaks of infiltration as occurring without cedema 
of the leg's. I have never met with such an instance ; nor do I 
well know how it could occur except from a blow, in like manner 
as occurs in the eyelid, which is not rarely infiltrated from blows 
upon the forehead. In case of any purely topical infiltration, it 
is to be expected that the water will immediately begin to flow of! 
into the adjacent meshes ; and, therefore, it will not require any 
medical prescription, beyond, perhaps, some cooling lotion, such 
as a dilute mixture of Goulard's extract, and water; or a weak 
solution of muriate of ammonia in vinegar and water, with the 
addition of tincture of opium. Cloths wrung out of such a solu- 
tion should be applied to the swellings. Half an ounce of the 
salt, a gill of vinegar and a tablespoonful of laudanum, mixed 
with a tumbler and a half of water, is the mixture that I com- 
monly employ. 

I have never found any inconvenience to result from fine punc- 
tures of the labia, as above recommended ; and I believe that it 
is best to make them, whenever the inducement is of sufficient 
weight. I made such punctures in a bad case under my care a few 
years ago, during the process of distending the genitalia externa 
by the child's head. I found that the packing of the cellular 
structure of the labium with water was so very firm, as to prevent 
the yielding of the parts. Very soon after I had made the open- 
ings, the water within began to exude ; whereupon, I delivered 
the woman with the forceps, without injuring her at all. 

Now, you may very readily understand that where the cedema of 



62 (EDEMA LABIORUM. 

the lower limbs has gone to the greatest extent, and the cause of the 
production of it still continues in force, not the labia pudendorum 
only, but the belly and chest, and even the upper extremities and 
head, have their cellular membrane filled ; a sample by no means 
difficult to find in practice. I am sure I have seen a woman in- 
creased in weight at least thirty pounds, or more, by this infiltra- 
tion alone. 

You will also understand, that such a great oedema gravidarum, 
must, to a certain degree, interfere with the health, and that the 
labor is likely, on that account alone, to be a bad one. But a bad 
labor sometimes requires you to resort to the aid of the forceps, 
while the head is still pretty high up in the pelvis. This being 
the case, you cannot adjust the forceps to the child's head, without 
carrying the lock very far backwards, and thrusting the anterior 
edge of the perineum far towards the anus and the coccyx. This 
you will be incapable of doing if the perineum be much infiltrated, 
thickened and hardened, so as to resemble rather a piece of deal 
than the ductile material of which it naturally consists. I have 
been baffled in all attempts to get the blades of the forceps adjusted 
by this resistance of the infiltrated perineum, but, when I have let 
the infiltration flow off through my punctures, then I rendered the 
perineum ductile again, and so could push it backwards and get 
my instrument in situ. 

Dr. Dewees appears to have treated some of the cases by 
venesection, by saline cathartics, and by doses of nitrate of potash 
repeated thrice a day. I believe that but little well-founded ex- 
pectation of a cure of the oedema can be indulged until the ter- 
mination of the pregnancy; when the mechanical pressure of the 
gravid uterus being withdrawn, there is no further effusion of 
serum into the cellular laminae; and the fluid of infiltration being 
taken up by the absorbents, the dropsical appearances soon 
vanish. You ought to expect, however, and you should predict, 
that your patient, who has suffered the extreme of this oedema, 
will look pale, and be, in fact, feeble and ansemical for some time 
after the close of her gestation. As a general rule, she will 
demand the use of a nourishing diet, wine, and iron, as the 
most likely means to re-establish her haematosis. 

In one of the worst cases of this oedema I have ever seen, Mrs. 

, a case in which I was seriously concerned for the 

safety of the lady, I found that the expulsion of the child was 



(EDEMA LABIORUM. 63 

immediately followed by a very great diuresis, which removed 
within eighty hours the last vestiges of the vast and general in- 
filtration. It is rare, I think, to find the most hydropic leg con- 
taining any serum three days after the child is born. 

In the course of your practice you will be often called on to 
advise, on the subject of oedema gravidarum. As it is extremely 
common for primiparous women to have swollen legs in the last 
six weeks, and sometimes earlier, of their gestation, you ought 
never to forget that such a woman is more exposed than another 
to the alarming attack of eclampsia, or puerperal convulsion. In 
fact, I have known but few other worn en to have convulsions in labor 
than those with swelled legs. The pressure of the gravid womb 
on the ascending blood and the absorbents, causes the effusion 
of serum; the same pressure, be it observed, is exerted on the 
aorta, impeding the descending current of blood, and of course 
directing a more abundant circulation in the trunks and branches 
of the subclavians and carotids; the consequence of which is an 
augmented arterial determination to the head and upper extremi- 
ties. If you permit this morbid determination to continue unmiti- 
gated, the slow but sure foundation is laid for puerperal apoplexy 
and eclampsia. The woman should be bled and dieted in a 
prudent and careful way, and all massive obstructions arising 
from a surcharged state of the colon ought to be obviated by 
gentle laxatives. 

I repeat that I do not think you can reasonably expect to cure 
a considerable oedema by venesection; yet that it may be mode- 
rated by the use of the lancet and kept within safe bounds I do 
not doubt. 

I shall close this letter here, with the design of speaking to you 
in the next, of certain other disorders to which the labia are sub- 
ject; — and I am very truly your friend and servant, 

C. D. M. 



64 WOUNDED LABIUM. 



LETTER VI. 

WOUNDS, LACERATIONS OF LABIUM. 

Gentlemen: — I design in this letter to say something as to 
certain very distressing injuries of the labia, suffered by partu- 
rient women, and which are caused by the extreme tension of the 
labia themselves, or by the tension of other parts, whose accidents 
or diseases, implicate these external textures. 

You are acquainted with the origin of the pudic artery from the 
ischiadic, in some individuals, and in others from the internal 
iliac ; and you are aware that this vessel runs upward on the inner 
face of the ramus of the ischium, and sends branches forth to supply 
the external organs. Now, it occasionally befalls a woman in 
labor, or one affected by a wound, to fracture this pudica interna 
artery, or a considerable branch of it; — and as the labium ex- 
ternum is full of loose cellular tela, it is easy to see how a rupture 
of the vessel may cause such a quantity of blood to be dashed 
into the distensible texture within the labium, as to give the ap- 
pearance of an enormous tumor, of a very livid or even black 
color ; and producing all the pain to be expected from laceration 
of the inward textures, and the stretching of the others not imme- 
diately broken, by quantities of congealed or fluid blood, with 
which the organ becomes thoroughly soaked and filled. 

The rupture of a vessel within the brain may suffice to tear the 
brain like a wooden wedge driven into it. So, in the spleen, a 
vessel giving way tears that organ to pieces — and, in like manner, 
a broken trunk or branch of the pudic artery, may demolish the 
internal texture of the labium majus. 

I have seen examples of the accident of various degrees of se- 
verity. Some of them were discovered before the termination of the 
labor, and others not until many hours subsequent to the accouche- 
ment. In the cases where the mischief is not complained of until 
long after the child is born, we may infer that the vessel is an 
arteriole only, — some branch of the pudic; which had given way 
during the expanded state of the inner genitalia, and which could 



LABIAL THROMBUS. 65 

not bleed while they were so expanded ; but commenced to scatter 
the extravasation within them, as soon as the distending and com- 
pressing cause was withdrawn. Such cases are less likely, I 
think, to prove mischievous, than the other sort, in which the 
labium begins to swell before the child's head has descended so 
far as to push the labium aside. When the labium fills in this 
way, antecedently to the emergence of the presentation from the 
arch of the pubis, we must suppose it to arise from the rupture of 
a trunk, not an arteriole. It is, therefore, more dangerous. 

The quantity of fluid thus extravasated is surprisingly great ; 
and doubtless the bloody infiltration will run backwards into the 
loose cellular laminae that are in relation with the sides of the 
vagina; producing disorder and difficulties to an unknown extent 
within; in addition to the more visible and tangible marks of them 
on the front of the pelvis. 

A lady in this city was in labor of her first child in , 1844, 

and after long-continued efforts to dilate a rigid os uteri, drove 
the head into the vagina, where it rested, on account of a com- 
plete cessation of the pains, from exhaustion of the supply of 
uterine innervation. Her medical attendant, intent on procuring 
the expulsion of the foetus, administered to her a portion of secale 
cornutum, the influence of which was soon manifested by the 
renewal of the labor contractions in great force. The ergotic spasm 
thus excited, gave way, after no very long interval, from a second 
exhaustion of the nervous energy directed into the womb ; — and 
it was found that the left side of the vagina, the parts about the 
left crus ischii, and the left labium, were swollen, tense, and 
painful. Being called to a consultation upon the case, I observed 
a large protrusion of the left half of the perineum, occasioned by 
bloody extravasation, which had gone so far backwards, as to fill 
the cellular material in front and to the left of the rectum ; while 
the looser texture of the labium had been rendered by it as turgid 
and dark as possible. 

It would have been impossible to extract the foetus from such 
a canal as was thus prepared, and as the indication was to use 
the forceps, I prepared the way for their successful application by 
making an incision into the inner and lower surface of the labium, 
out of which I extracted by means of the finger, which passed far 
inwards, a great quantity of coagulated blood, besides much fluid 
blood and serum; which being done, I next adjusted the forceps 
5 



66 LABIAL THROMBUS. 

to the head, and painfully, slowly, and with much effort, extracted 
the child, which was dead. 

The patient w T as sorely exhausted by such a dreadful labor. 
Her very bad pulse did not amend after the delivery; the injured 
parts were attacked with erysipelas, to which she fell a victim, in 
the course of a few days. 

I have thus given an account of a case which I hope may set, 
in a clear point of view, the nature ^nd dangers of these bloody 
infiltrations; and I wish the perusal of it may set you on guard 
against similar occurrences, of which you will perhaps become 
the interested spectators. I should think the foregoing remarks 
enough to show you that the mere filling up a labium is a matter 
of small consequence, in comparison with the inward mischief 
and demolition likely to accompany such accidents. I pray you, 
then, not to disregard the complaints of your patients in child-bed, 
as to the affections of the external genitals ; but the rather, that 
you should pay very great regard to them, nor suffer the fastidious- 
ness of a modest female, or your own sense of delicacy, to prevent 
a complete and early investigation. 

Do you not think that if a patient under your care, in labor, 
should begin to have extravasation (thrombus) filling up the 
labium, it would be charitable, and dutiful, and prudential to lay 
open the mucous surface by an incision conducted in the longi- 
tude of the organ, and deep enough to give issue to the infiltrating 
blood? Would not such an aperture, by allowing the hemorrhage 
to exhaust itself upon cloths or napkins, prevent it from tearing 
to pieces, or obstructing the lax textures outside of the vagina 
and inside of the pelvis? Be you the judges to decide upon any 
case presented in the course of your practice. I think, that where 
a labium is already filled with blood, before the distending power 
of the head begins to be exerted upon it, if you allow the injecting 
force of the hemorrhage to go on unchecked or unrestrained, you 
w T ill have reason to dread the extending of the thrombus to very 
deep-seated textures; and hence I should much prefer to allow 
the fluid to escape through an incision made on the mucous face 
of the labium. 

I pray you to consult Dr. Dewees' article on this subject, in 
the Treatise on Females; it is a very good one, and you ought 
certainly to consult the writings of that celebrated man — the more 
especially as he was an American authority. 



LABIAL THROMBUS. 67 

I have said nothing of the after treatment of the accident. Of 
course, you will not expect to discharge from the thrombus all the 
blood contained in it, by an incision. You will get out all the 
coagula, very great in quantity, and pass out much fluid blood 
and serum of the coagulations. The discharge of the rest will 
take place, partly by outflowing under the textural contractility 
of the parts, and partly by the absorbents, which will carry it 
away. I am sure I have seen at least a pint of blood effused be- 
neath a man's skin, from a blow, taken up and carried away by 
the absorbents in about a fortnight. 

The most convenient treatment will consist in very emollient 
dressings, either of tepid water, mixed with a little red wine or 
vinegar, or of flaxseed tea, mucilage of slippery elm, applied as 
stupes or fomentations, or linseed or bread and milk poultices, 
or poultices composed of crumbs of bread mixed with the petals 
of chamomile. These dressings, when the tumefaction becomes 
sufficiently reduced, ought to be followed by cerate dressings ; whe- 
ther of simple cerate, basilicon, or Goulard's cerate. The selection 
will depend on your judgment as to the wants of the case. 

When a woman has suffered from such an accident, it must be 
expected, if the injury be of a grave character, that she will have 
great pain and constitutional disturbance from it. I need not 
say, that you ought not to leave the nerve system to the un- 
mitigated perception of such painful impressions ; but that you 
ought to quell both its impressible and perceptive faculties, by 
keeping them within moderate bounds, by the use of anodyne 
medicines in some convenient form ; such as the Dover's pow- 
ders, which may be repeated in doses of four grains every two, 
four, or six hours, until the therapeutical end of its exhibition is 
attained. 

Should much febrile heat, and sanguine exaltation attend the 
early stages, you might perhaps prefer a medicine like the follow- 
ing recipe. 

Take of fresh lemon juice, 1 tablespoonful ; carb. of potash, 
18 grains ; mix them and add, solution of sulphate of morphia, | 
of a grain to make a draught, to be taken every two, four, or six 
hours. 

It will be obvious also, that where a full or tense pulse is found 
to accompany the accident, or to follow it as a consequence, it 



68 LABIAL THROMBUS LACERATION. 

may be needful to reduce the force of the sanguine circulation, by 
venesection, to a proper extent. 

During the treatment, the bladder of urine should not become 
overfull, and the alvine dejection should be procured at least once 
in twenty-four hours. The most scrupulous cleanliness, as to the 
parts, ought to be insisted on — and all sour poultices, or remain- 
ders of dressings, carefully expunged. But all these precautions 
would be of little avail, without the most profound recumbent rest. 
She should not leave her couch until cured. 

Watch such a patient vigilantly. She is always to be esteemed, 
until suppuration is established, in danger of erysipelas of the 
wounded parts. If attacked with erysipelas, she will scarcely 
escape death from peritoneal fever. I say then, watch such a 
patient well, through the dangerous five or six days ensuing the 
accouchement. If the disposition to erysipelas become manifest, you 
should apply the nitrate of silver pencil freely to all the inflaming 
skin, if not to the very margin or lips of the wound. The anti- 
phlogistic power of the nitrate, is probably the most dependable 
of your resources for such circumstances, and may be handled so 
as not to give any pain. C. D. M. 



LETTER VII. 

Besides the affections I have now treated of in the two former 
letters, the labia externa are subject to rupture or laceration, not 
attended with the terrible conjunction of concealed hemorrhage, 
last spoken of. Indeed, it would, a priori, be evident to you, that 
a fracture of the tissue, laying it open to the air, would not con- 
sist with the formation of a thrombus within its walls. 

It is always a subject of regret, when the labium is torn in 
labor ; for I presume that no professional rank or station of the 
accoucheur, could preserve him from the maligning tongues that 
are so fond to wag against their betters. The more exalted your 
station, the more will you be liable to the assaults of the envious 
and the malignant ; who will not fail to spread abroad the bruit 



RUPTURED LABIUM. 69 

of the misfortune, accusing you of ignorance, inattention or rash- 
ness ; and averring that you tore her dreadfully; when they do not 
know, that your knowledge of Professor Cams' curve and the 
agents in the extension of the head, with your own probe and 
faithful regard to duty, could not, all combined, prevent the inno- 
cent head of the child from breaking in pieces an obstruction 
which it could not otherwise overcome. 

I doubt not, my friends, after the repeated illustrations made in 
your presence, that you perfectly understand why it is the head 
of the child, which in vertex presentations enters the pelvis ob- 
liquely and in flexion — descends and rotates still in flexion, until 
the occiput, engaging under the crown of the pubal arch, is 
pressed upwards, as it emerges, along the exterior face of the 
symphysis, being compelled to move so, coincidently with Cams' 
curve, by the strongly resisting perineum, against which the 
sagittal suture is driven by the labor throes. 

You may remember that I urged you not only to aid the peri- 
neum to compel the extension, but to aid it in compelling the head 
to move out in coincidence with Cams' curve; and that because, 
should it quit Cams' curve at a tangent, the perineum must give 
way, or a labium be broken off, or perhaps both of them be de- 
tached somewhere in their longitude ; a horrid accident, which I 
trust may never occur in the hands of any member of the class. 

Only conceive of a rent commencing at the lower end of the 
labium, and running back through the whole thinned structure of 
the perineum, not thicker than this sheet of paper sometimes, so 
as to burst through into the rectum. Take care then, I pray you, 
of the women, who under faith of your diploma, or your acknow- 
ledged skill, commit such precious interests into your charge. 

Let me warn you against the risk of cutting the perineum with 
the child's elbow. You will be very apt to allow the accident to 
happen whenever the child's hand, in a vertex presentation, 
descends, applied to its face or throat; for the ulna of the 
child lies in contact with the posterior wall of the vagina, and as 
it slides forth, and comes to press with its olecranon on the four- 
chette, that olecranon cuts the tissue like a sharp knife — whence, 
I beg you be careful to prevent the accident, which I have so 
often told you can only be prevented by supporting the perineum, 
knowing why, and how it is to be supported. 

Such a laceration as I have now mentioned, is very difficult of 



70 RUPTURED LABIUM AND PERINEUM. 

cure, and will not be cured, provided any sloughing process 
should attend the inevitably consequent inflammation. If un- 
cured, the woman becomes converted into a monotreme, and is a 
pitiable object for the balance of her existence here. Take you, 
then, scrupulous heed to the tedious doctrines of the mechanism of 
the pelvis and head in labor, and never lose sight of them in con- 
ducting your cases, and especially your cases terminated with 
instruments. I have been for many years engaged in midwifery 
practice to a great extent of occupation, and I defy any one to 
point out the sample of a female who has suffered under any 
durable lesion or disability of the organs concerned in the trans- 
mission of the foetus, under my administration over labors. I 
confess I take pleasure in claiming the merit of such a success, 
not as impertinently arrogating any superiority of skill over my 
brethren, but as evidence of the good results that must ever attend 
a watchful care over those who are committed to our hands. 

When a labium gives way in labor, it is because of some too 
sudden and violent an exertion of the expulsive force of the 
womb and the abdominal muscles in the last agonies of the 
labor throes. The tenesmic sensations and propensities of a 
female, whose perineum is frightfully extended by the presenting 
part, are so irresistible, that she cannot be prevented in some 
cases — I might say in many cases — from an involuntary and 
excessive effort to free herself from them ; and I have made it a 
rule to give due warning beforehand of strict obedience to the 
directions I should give as to not bearing down the pains ; and then, 
reflecting on the causes of the extension of the head, and the 
direction of the axis of the plane of the perineal strait, have 
safely guarded my patient against injury. 

Do not, I pray you, accuse me of quitting my proper task here 
in order to talk to you again of a purely obstetric subject. I am 
well aware that my letter relates to the accidents that befall the 
labia and perineum ; but I cannot forget the sound though homely 
adage — that prevention is better than cure; and I deem my re- 
marks germain to the subject in hand ; and hope that they may 
serve, if not to eschew fractures of the labia in the whole, yet, at 
least, to render them less extensive and mischievous; nor do I 
doubt of your success in eschewing them, if you should suffer 
yourselves to be governed by these views. 

When the accident has occurred, there is but little reason to 



RUPTURED LABIUM AND PERINEUM. 71 

hope for union by the first intention, as the surgeons call it. 
How, indeed, could we expect such a union of parts not cut 
asunder by a sharp instrument, but torn by violence. The raw 
surfaces are surfaces of laceration, and can, in the general, only 
be reaccommodated by the process of granulation — a tedious 
process. 

It will not be necessary to keep them in contact by sutures — 
plasters cannot repose upon surfaces continually bathed by the 
lochial, mucous, and purulent as well as urinary excretions. 
The suture only adds to the sum of the local injury, and is not 
unapt to generate an erysipelatous propensity in the parts. Sutures 
are not necessary to keep the surfaces approximated, and when 
that is done, the chirurgical indication is fulfilled. The stupes of 
warm wine and water, of mucilages, the poultices, and cerate 
dressings, together with a prohibition to abduct the thighs, are all 
that ought to be ordered, beyond the scrupulous regard to clean- 
liness that must be obvious to every one interested. 

It is a good precaution to fit a garter to each leg, and to tie 
them by a tape, in such manner as to prevent any inconvenient 
abduction of the knees. Most of the cases of considerable lacera- 
tion, whether of the labia or perineum, may be expected to recover 
by the time the purification of the woman is complete — say within 
the month. 

I have to state that I have met with cases of injury to the pe- 
rineum by laceration, where union had never taken place, and 
would never take place ; because, in fact, the anterior perineum 
being divided as far back as the rectum, laying that intestine 
quite open, the sides of the cut became each incarned and covered 
with a real mucous membrane, so that the woman, instead of 
having a vagina and rectum, had only a true cloaca, into which 
was discharged the products of the rectum, the uterus, and on 
some occasions parts of the urine ; for the posterior semi-circum- 
ference of the anus was now converted into the posterior commis- 
sure of the vulva. So that, in fact, the labium extended back to 
the inner wall of the anus on each side. Even in such a dread- 
ful case as this, the lady rarely is affected with any leakage from 
the gut; but discharges the alvus as regularly as any other per- 
son, save when attacked with diarrhoea. Her protection from the 
disgusting incommodity of non-retention of the l\rces, is owing to 
the conservatism of some of the upper bands of the sphincter of 



72 INJURED PERINEUM PROCIDENTIA. 

the rectum, which I have found to close very completely the new 
formed anus, which was invisible, because concealed within the 
depths of the new accidental vulva or cloaca. Where all the 
fibres of the sphincter are lost, there must be a very constant 
drain of offensive matters from the intestine: enough to render 
the creature an object of pity to others, and of aversion to her own 
conscious self. Life, to such an individual, is rather an insup- 
portable burden than a boon. How anxiously should you, there- 
fore, direct the resources of your information to obviate such a 
great disaster. 

I may as well, in this connection, call your attention to another 
circumstance. It is this — the perineum being taken away, 
the vagina torn open very far upwards, and its strength thus 
reduced, — the unhappy female endures not a prolapsion only, but 
a true procidentia of the womb, which descending more and 
more with the progressive advance of age and debility of the 
parts, causes the patient to endure much pain, and to become 
subject to erosions and inflammations of the extrophied tissues. 
Y.ou cannot sustain them with a globe, a disc, or an elytroid pes- 
sary ; but you can always keep the prolapsed parts high up within 
the pelvis by that admissible stem-pessary of Dr. James Blun- 
dell, which I exhibited to you during our meetings in the lecture 
room. I am pleased to find myself able to assure you, that good 
hopes maybe entertained, therefore, as to the means of comforting 
those who become the subjects of these great obstetrical catastro- 
phes — for to be connected with the management of a case, that 
offers no hopes of a remedy during a long lifetime, is to be truly 
unhappy. 

In addition to the affections of the labia above mentioned, you 
should make yourselves aware, that the textures within the mucous 
surface of the organ, are capable of developing cysts, and also 
more solid tumours. These cysts sometimes attain a considerable 
size. 

Upon pinching such a cyst betwixt the thumb and finger, or 
upon pressing it with the palp of the forefinger, it is observed to 
be soft and fluctuating. There is little pain accompanying it 
necessarily; but the presence and pressure of the sac may induce 
pain at last in the surrounding textures. There is some danger 
of making a mistake in the diagnosis, provided one be careless in 
his inquiries. For example, a lump, or tumour within the labium, 



CYSTS WARTS OF THE VULVA, 73 

might consist of a hernia of a portion of the bladder; and it is within 
the bounds of possibility, that the tumour should be formed by a 
descended knuckle of intestine. I am sure, however, that not one 
of you will ever be so imprudent, as to venture on discharging' 
the contents of any labial tumour, by means of the lancet, or bis- 
toury, without first taking care to ascertain the true nature of the 
case. The cyst itself will always be found perfectly circum- 
scribed, movable, fluctuating, and indolent. 

The surgical method of treatment, consists in dissecting out 
the whole sac. If you merely open it, and allow the contents to 
escape, the organic apparatus, being undestroyed, you may ex- 
pect the sac to fill again. Perhaps, however, were you to fill the 
cavity with port and water, or with a solution of iodine, you might 
reasonably expect to produce granulating inflammation, which 
would obliterate the cavity ; or it is an easy and prudent step, to 
pass a seton through the centre of the sac — using for that purpose 
a very large, curved surgeon's needle with two or four strands of 
silken thread. Inflammation thus excited would, after withdraw- 
ing the seton in three or four days, in all probability cure the 
evil, by obliterating the special secretory membrane. 

Women are sometimes plagued with a growth of verrucae or 
warts, that spring in dozens or hundreds from the whole surface 
of the sinus pudoris. They are in certain cases, so abundant as 
to dispart the labia, filling up the entire sulcus, and rising as a 
great convex mass of pale cauliflower looking tumour, quite convex 
above the general level. Upon pulling the labia further apart, so as 
to open the sinus pudoris, they are perceived to be small warty 
excrescences from the mucous body of the mucous membrane, and 
differ not from the warts on children's fingers, except by their 
greater softness, which depends on their being always bathed 
with the sort of milky humor of the labial membrane. They 
often bleed when touched, and when pinched off with the finger 
nails, the broken surface trickles with blood, which soon ceases to 
flow. I have found that, when the entire labium right and left, 
has been quite incrusted with warts as above, I could with the 
probe separate them anywhere, for they are distinct from, though 
in lateral contact with one another. You will readily include a 
great number of them in a ligature, which being tightly tied, they 
drop off after some hours. 

The readiest way to remove them is to snip them oil', several at 



74 DR. 

a time with scissors, curved on the flat. This being done, and 
the surface being lightly touched with the nitrate of silver pencil, 
or with a solution of sulphate of copper, the mucous tissue is not 
very likely to reproduce them. I doubt not they are hypertro- 
phied papillae of the corpus mucosum of the genito- urinary tissue. 

There occurred a very singular case under the care of Professor 
Brainerd, of Chicago. I shall take the liberty of laying before 
you a copy of his letter, describing the case, for which I trust he 
will receive as my apology, the great interest inherent in such an 
occurrence, and the desire I have that you should all have the 
opportunity to follow his example of treatment, should you happen 
to meet with individuals similarly affected. 

The letter is addressed to Dr. J. F. Meigs, of this city. 

Chicago, February 20, 1847. 

Dear Sir — Accompanying this you will receive a specimen of 
morbid growth, of whose nature I am very doubtful. Knowing 
the interest you take in the diseases of females, and the researches 
your father has made in relation to all classes of these affections, 
I have sent you this in the hope that, by his aid, you would be 
able to enlighten me in relation to its class and character. 

The little girl from whom it was taken, is the daughter of 
healthy parents, residing in Du Puy Co., Illinois, is nineteen 
months old, and was first seen by me on the 29th of January, ult. 
On examination, the abdomen was found to be much enlarged, 
an oval tumor extending from the pubis to the umbilicus, which 
gave the sensation of fluctuation. From the vagina there pro- 
jected a substance having every appearance of a common gelati- 
nous polypus of the nostril, being about an inch in length, and 
two lines in thickness. The urine was constantly dribbling away, 
the bowels constipated, much emaciation, and derangement of 
the health. 

The history of the case was as follows. Nine weeks previously 
there was noticed a discharge from the vagina, mucous at first, 
and afterwards occasionally bloody. When this had continued 
four weeks, small semi-gelatinous bodies of the size of peas were 
discharged with it from time to time. At length the gelatinous 
bodies began to protrude from the vulva, the protrusion being 
preceded and accompanied by pains and straining, which were 
compared by the mother to those of labor. When exposed to the 



75 

air these bodies soon became red, then brown; shrunk, and 
sloughed, and were succeeded by others, which in turn fell off. 
The enlargement of the abdomen was more recent than the dis- 
charge. 

Judging from the fluctuation and the almost constant discharge 
of urine, that the abdominal tumor might depend upon retention 
of urine, I introduced a catheter, and found this to be the case; 
about twenty-four ounces were discharged, and the tumor entirely 
disappeared. Directing my attention then to the growth pro- 
truding from the vulva, I introduced a nasal polypus forceps into 
the vagina, seized it, and, with but slight force, separated and 
brought it away. This was repeated several times, and each 
time a reddish body, resembling a gelatinous polypus of the nos- 
tril was extracted. Finding the vagina still full and distended 
with such growths, I desisted from further attempts, and, on the 
first of February, inst., made use of the double canula and liga- 
ture, as for uterine polypus, embracing as much as possible of the 
growth. On tightening the ligature, it readily divided the parts 
embraced, and the withdrawal of the canula was followed by the 
discharge of a great number of the same substances; but, by 
scarcely any hemorrhage. 

This operation was repeated either with the ligature or forceps 
daily, for a week, and each time a large number of pieces were 
obtained, one dozen each day would be a low estimate ; and every 
day they increased in number, but diminished in size. Finding 
this to be the course of things, I introduced a sponge tent for the 
purpose of dilating the orifice of the vagina, which had been al- 
ready to a great degree effected by the protruding bodies, and 
soon effected my object, so as to allow of the introduction of the 
finger very easily. The vagina was found dilated so as entirely to 
fill the pelvis, pressing upon the rectum and urethra, and rising 
above the superior strait, its sides were invested by the same 
bodies which had been extracted in such quantities. They ad- 
hered firmly over the greater part of its surface. Scraping it with 
as much force as was safe with such a structure, the finger was 
withdrawn, and immediately from fifty to one hundred of the 
bodies of small size followed. This operation was repeated daily- 
several times, until but few followed, and there only remained 
behind an indurated spot upon the posterior surface of the canal, 
which seemed a matrix for the whole, and which could not be 



76 

detached by moderate force. Having found, by the number and 
rapid growth of these bodies, that they would undoubtedly be re- 
produced, the next point was to prevent this danger, and it oc- 
curred to me that some substance capable of coagulating albumen 
promptly, without acting too energetically upon the animal tissues, 
would succeed. A strong solution of alum was chosen and in- 
jected, a compress being applied to retain it. This was followed 
by the discharge of much coagulated albumen, of which thick 
layers were every day removed from the indurated points of the 
walls, until they seemed natural. The injection of alum-water 
was continued for several days longer, simple warm water being 
also used for cleanliness. The discharge gradually diminished 
and ceased. 

At the last examination, the vagina was contracted so as barely 
to admit the finger, and seemed perfectly natural. The os uteri, 
which had not been distinctly felt before, was perceived, in form 
of a small tubercle, the orifice just perceptible, showing the uterus 
to have been unaffected. 

The urine required to be drawn for the first week, but since 
she has gradually re- acquired the pow T er of discharging it ; gra- 
dually improving in health and appearance until the present time, 
when she may be said to be quite well. 

Some of the bodies removed in this case are the specimens sent, 
and you have only to suppose them larger, softer, and semi-trans- 
lucent, and you will form an opinion of what they resembled 
w T hen first discharged. They are only changed by the effect of 
alcohol. They were distinctly vesicular. The largest were an 
inch and a half in length, and an inch broad ; the smallest not 
more than a fiftieth part as large. 

At first I supposed them to be polypi, but soon perceived that 
such was not the case, since they had been discharged and re- 
moved to the number of several hundreds in all, and were evi- 
dently attached one upon the other in some points. So that I 
know not what they may be, unless it is an animal growth, allied 
to the acephalocyst, of which there are, I believe, several kinds, 
found sometimes in animals, and of which this may be a rare 
or unknown variety. Will you present the case, with my respects, 
to your father, and inform me, if convenient, of the opinion he 
may form of it ? Very sincerely, your friend, 

D. BRAINERD. 



PRURITUS VULViE. 77 

Dr. Brainerd sent several of these curious bodies. I found, 
on examining them with a good doublet, that they were not 
cysts, but solid bodies, more resembling a mere sarcode than 
anything else. They were without hooks or other apparent appa- 
ratus. I could not adopt Dr. B.'s supposition that they constitute 
a variety of the acephalocyst, and like Dr. B. I remained uncer- 
tain as to their nature ; but rather inclined to believe that they 
consisted of a morbid production of the corpus mucosum of the 
vaginal membrane. 

I sent them to Mr. Milne Edwards, the zoologist, at Paris, and 
hope to have his decision as to their character. Should Mr. Ed- 
wards ascertain and state their real nature, I hope to communi- 
cate his opinion to you. 

There are a great many women, who when pregnant, are an- 
noyed with a most distressing, and even intolerable pruritus of the 
vulva, affecting chiefly the inner face of the labia, mainly attack- 
ing the portions of them in a range with the nymphae, and not 
irritating so severely the parts nearer the posterior commissure. 
The malady is not confined to the gravid female alone, but I should 
suppose that ninety per cent, of the instances I have met with, 
have been in women enceinte. 

Dr. Dewees appears, at times, to have found the mucous surface 
affected with aphthous inflammation. I have not seen such a 
case, though I have met with some that were to the last degree 
distressing cases, in which the pruritus was so intolerable, that 
the person could not resist the provocation to scratch, and even 
wound the surface with her nails. In such a state I have found 
the mucous body of the membrane red, of a Modena color, very 
dry and hot, but I have not observed aphthse. In certain other 
samples, the dryness and redness were wanting ; nor was there 
any sensible increase of the heat. 

Should you be invited by your patients to give counsel on such 
a complaint, I advise you to make careful inquiries as to the 
presence or absence of redness, dryness and heat ; and where 
they exist in a subject not demanding or admitting the use of the 
lancet, to recommend the application of a few, say eight or twelve 
leeches, within the labial surfaces. If the signs be absent, it may 
not be worth while to trouble your patient with the leeching. 

Some cooling laxative will be indicated in case of torpor of the 
bowels ; and a conformable diet should be prescribed. In such a 



78 PRURITUS CICATRIX ABSCESS. 

patient, salted meats, gravies, spice, pepper, spirituous and vinous 
drinks, ought to be forbidden. The warm bath, or the hip bath, is a 
highly useful ordinance ; and some proper lotion or application 
should be provided for the affected parts. 

It seems obvious that this must be a case for the nitrate of 
silver to show its alterative powers; for if there be any sample of 
disease that would be likely to yield to it, this would seem to be, 
most probably, the very one. Yet, I am constrained to say, I 
have not found it to answer the purpose. Nor does vinegar, nor 
mucilage, nor cold, nor tepid water, nor laudanum and water, 
nor alum cure it; but this is true, viz., that very few cases fail 
to be either cured or kept within very moderate bounds, by the 
following recipe : 

Take of biborate of soda, half an ounce; distilled rose-water, 
six ounces ; sulphate of morphia, six grains. Mix, and direct the 
lotion to be applied to the part affected many times a day. 

Every man becomes probably more or less a routinist in his 
methods. It is with me a routine to order the above compound 
lotion ; and I aver to you, that I believe, if you order it for your 
patients, you will have very little trouble in curing them. I am 
speaking here of the general run of cases. Should you use this 
compound, and find yourselves disappointed as to its curative 
powers, you ought to request an opportunity to examine, by in- 
spection, the peculiarities of the malady, in order to enable you 
to judge whether blood-letting, purging, emollients, nitrate of sil- 
ver, or astringents and tonics should be preferred. 

Ancient injuries,, by laceration, by ulcers, and by fevers, may 
have contracted the external parts so much as greatly to interfere 
with the dilatations required for the transmission of the child in 
labor. Patience can, perhaps, overcome even the contractions of 
old cicatrices ; but when you are called on to give your opinion 
in such cases, you would do well to have at the call of your 
memory the views of Dr. Dewees, who taught us that the most 
resolute cicatrix may be rendered dilatable under the influence of 
bleeding, ad deliquium animi. I have met with no such cases 
myself. 

The labia are frequently the seats of a phlegmonous inflamma- 
tion. The texture of the organ being very lax and distensible, 
the abscess formed within it generally points early, and always 
points on the mucous surface. I never yet met with one that did 



THE NYMPHSE, 79 

not end in suppuration; not because suppuration could not be 
prevented, but because the woman will never call for counsel 
until it is too late to expect any other termination. It is a sim- 
ple matter, though a very vexatious and painful one. 

You should open the abscess as soon as the fluctuation of the 
pus can be made out. The pain disappears with the cessation of 
the tension upon the escape of the pus. It is very common for a 
woman, who has had one labial abscess, to be troubled with 
several consecutive attacks of the same kind. 

With these remarks, which appear to me sufficient to set the 
matters in question in a clear light, I have to conclude this letter 
with the assurance of my respectful consideration. 

C. D. M. 



LETTER VIII. 

Gentlemen :— There is another part of the system of organs 
contained within the pudenda, which deserves your professional 
attention, I mean the labia minora, or, as they are more generally 
denominated, the nymphse ; quasi custodes castitatis. 

They are composed of an external or mucous membrane, within 
which there is an erectile spongy texture, which gives to them in 
the young, a certain degree of firmness, or hardness, that is not to 
be observed in individuals reduced by disease, or those who are 
advanced in age. 

In the young and healthy female, the labia minora are of a 
rosaceous hue, which for such as have borne children, gives place 
to a dark, or even brownish tint. They are also much changed 
by the repeated excitement of the sexual passions, and are often 
after labor, discovered to be permanently enlarged, or torn and 
ragged or jagged on their edges or sides, by the violence done to 
them during the extremest extension of the parts, by the out- 
passing child, or by the edges of instruments employed in its 
delivery. 

In a young child newly born, it is usual to find the nymphse 



SO THE NYMPHS COHESION. 

jutting out beyond the genital rima — but very early — say by the 
end of the 14th or 20th day, the development of the labia majora, 
which proceeds rapidly as soon as the foetal circulation is cut off, 
comes to cover up and wholly conceal the nymphse ; which, in 
the virgin, are not found to jut beyond the rima; whereas, the 
woman who has borne children, and who has suffered lesion of 
this organ in parturition, generally protrudes one, or both of them 
above or beyond the rima. 

The physiological uses of the nymphse are not agreed upon ; 
but it is strange to find that such a writer as Dr. Campbell, in his 
Introduction to the Study and Practice of Midwifery, p. 31, should 
say that "they are supposed to direct the urine from the urethra, 
and prevent its flowing over the external parts, and they contri- 
bute to enlarge the vagina during the exit of the foetus; for at 
this time they are quite obliterated." 

Pray observe that, should the stream of urine touch the lower 
end of the nymphse, it would be sure to flow over and bathe the 
whole perineum ; and you will not forget my assurances in the 
lecture-room, that I had very repeatedly found during the ex- 
tremest distension of the external genitalia, the nymphse hard and 
well marked along each side of the distending head of the child. 
You will find that Dr. Murat, in the article J\"ymphes of the 
Diet, des Sci. Med., avers that they do serve to the amplification 
of the vaginal orifice. It is incorrect to say so, since they belong 
not to the vagina but are a sort of valvular conniventes of the 
labia majora, to whose enlargement in labors they contribute not, 
or if I am incorrect in saying not at all, at least I am surely cor- 
rect to say very little. 

Fabricius ab Aquapendente, relates a case in which there was 
atresia of the vagina from imperforate hymen. The external part 
was protruded by the collection of the menstrua within. This dis- 
tension had so effaced the nymphse as to lead to the belief that the 
girl had none at all ; but when the collection had been discharged 
and the external organs recovered their situs, the nymphse were 
found to be perfect. This example is relied on by Dr. Murat in 
support of his view. But I ask you to consider whether the slow 
protrusion and development caused by a gradual collection of 
blood within the womb and vagina, might not introduce changes 
in the character of the formation within the sinus pudoris, which 



THE NYMPHS. 81 

could not be brought about by the rapid and rushing distensions 
of a common labor. 

If such an addition were necessary for such a purpose as is 
pretended, it is probable that it would be found in the other warm 
blooded animals ; but we have Mr. Lawrence's assurance, in his 
Comparative Anatomy, p. 452, that none of the mammalia possess 
nymphae, and there is, in general, merely a thin border of the 
integuments instead of labia pudendorum. 

In the case of diseased clitoris, of which I gave an account at 
p. 83 of my edition of M. Colombat's work, I carefully sought 
for the labia minora, and you will see, by reference to the cut at 
p. 84, that, notwithstanding the enormous tumor of the clitoris, 
they still preserved their visible physical character. 

What, then, is the use of the nymphse ? — what their physiolo- 
gical function ? It is to increase the surface of contact, and to 
bring the clitoris into contact, for the end to augment the aphro- 
disiac orgasm. That orgasm is probably essential as an agent in 
the fecundation of the germ, as without its intervention, it is 
probable the tubes could not apply their fimbriae to the ovary, and 
thus the ovulum would be lost. 

It belongs to all women to possess them. 

Among the various tribes of dark-skinned savages of Southern 
Africa, there is one called Bosjesman or Boschisman. Their 
women, it is averred, are all endowed with an appendage to the 
external organs, which is called the Hottentot apron — le tablier 
des Hottentottes, though the Hottentot women are without it — the 
production belonging only to the Boschisman women. One of 
these women died in Paris in 1816, and was dissected at the 
Jardin des Plantes. The tablier was found to be only a hyper- 
trophied state of the two nymphse, but so long and loose, and 
flap-like, that they could be turned up like hound's ears, above 
the symphysis pubis. It is a very remarkable ethnographical 
feature, and so far as I can learn, belongs to only one tribe, and 
that a South African one. The tablier, to a certain extent, may 
be met with as an accidental hypertrophy among women, here 
and there, of all races ; but that it should become an ethnographi- 
cal peculiarity is fit to excite our surprise. 

I find that our distinguished countryman, Horatio Hale, author 
of the Ethnographical and Philological results contained in the 
7th volume of the United States Exploring Expedition, makes no 
6 



82 TORN nymph!. 

mention of this structure as a feature of the numerous and diver- 
sified races in the South Seas. 

Travellers in Abyssinia assert that it is a custom practised by 
the quasi Christians, under the government of Selahe Salassie, to 
circumcise the females at an early age, by the excision of a por- 
tion of the nymphae, and it seems to have prevailed in that be- 
nighted land for centuries, probably from some misapprehension 
of the Mosaic injunction as to the rite for males. 

These organs are endowed with a very high degree of sensi- 
bility, and as they have a copious circulation within, are subject 
to attacks of inflammation, whether accidental or specific. I 
have often found them to be more or less lacerated in labors. In 
the general, such accidents happening to them have not required 
at my hands any special direction beyond that of keeping them 
as far as possible free from the irritating influence of sharp or 
acrid discharges. For the most part, the tissues within the sinus 
pudoris are maintained in an emollient state by the lochial excre- 
tion, and by the mucus which is yielded in great abundance by 
the genito-urinary mucous membrane. They do not, therefore, 
like a dermal and exposed surface, require lotions and emollient 
cataplasms, since they are buried within emollient surfaces. 

I advise you, however, to think, that if a woman be so unfor- 
tunate as to have a nympha half torn off', the monthly nurse ought 
to receive clear instruction as to keeping her patient very clean, 
by bathing the parts often enough with warm wine and water, or 
other convenient lotions, such as infusion of chamomile and lint- 
seed or slippery elm ; for there is a vulgar and disgusting notion 
that a woman must not change her napkin often lest she stop 
her discharge thereby; and some of them are so fully imbued 
with this prejudice that they will allow the accumulated out- 
pourings of the vagina and womb to putrefy on the napkins. 
Imagine the fetor that must accompany such a state of those 
putrescible materials hidden beneath warm bed-clothes, and with 
the patient perhaps at a fever heat of 101 degrees of Fahrenheit ! 

I hope that you will be able to exercise your proper authority 
as medical counsel, and help, within your sphere, to cast out of the 
popular mind not this only, but every error and vulgar prejudice 
that you may find to have descended from remote and barbarous 
ages. A young female, with whom I spoke about a week since 
on the subject of a sexual malady, assured me she had never 



THE VAGINA. 83 

been permitted to use any napkin during her catamenial periods. 
She had been early forbidden to do so by advice of the family 
physician, who insisted that the women who use some such re- 
ceiver are subject to a more abundant effusion ; and so the poor 
girl, for fear of a stoppage of her menses, was compelled for three 
days out of every twenty-eight to wear a soiled and bloody under- 
garment. What say you of such a counselor? 

I have not, in any case, found it necessary to secure the appo- 
sition of the torn edges of a lacerated nympha. Should you, 
however, encounter a case where the organ is badly torn, it will 
perhaps be thought by you prudent to secure the apposition of the 
edges by means of a suture, either consisting of a single stitch, 
or of two interrupted ones. 

I shall not fatigue you with any further remarks on the lacera- 
tions of the nymphae ; but shall defer to my next letter some 
remarks upon other affections of the parts under consideration. 
Meanwhile I remain, &c. &c. C. D. M. 



LETTER IX. 

THE VAGINA. — THE HYMEN, 

Gentlemen : — The organ whose maladies we are now about to 
study, is one of great interest to the obstetric practitioner, as well 
as to the physician, on account of the numerous and formidable 
maladies of which it is the subject. Connecting the external with 
the internal genitalia, and possessing relations to both, and to 
several other important structures, it will be well for you to give 
to the study of it considerable attention. 

It is a membranous tube, about four and a half inches in length. 
and capable of being considerably extended, on account of its 
great ductility. The interior of this tube consists of mucous 
membrane, whose free surfaces are continually lubricated with 
mucus, to prevent cohesion, as they are in contact in the living 
female. The mucous surface or coat of the vagina rests upon a 



84 STRUCTURE AND RELATIONS OF VAGINA. 

pretty firm exterior basis, which is composed of a dense laminated 
cellular tissue, containing many vessels, whether sanguine or 
lymphatic; with nerves that are in considerable numbers, and 
connected with distant and neighboring parts. 

I do not regard the coat, or texture, on which the mucous 
body of the vagina reposes, as a fibrous one; — for I cannot rea- 
dily comprehend why a fibrous tissue, save a muscular one, should 
be devoted to purposes so extraordinary as those to which it re- 
sponds. Is it not, indeed, manifest that a fibrous organ could not 
become the subject of those enormous changes that are necessary 
to enable a vagina whose mucous surfaces are in contact, to be- 
come large enough to admit of the birth of a child of seven, and 
sometimes of twelve, or even of fourteen pounds weight? 

I have, after careful investigation of the structure, come to the 
conclusion that it consists in a very compact cellular tela, a sub- 
stance well calculated to admit of the necessary expansibility; 
and elastic enough to cause it to regain its ordinary dimensions, 
not very long after the birth of the child. The submucous tissue, 
or laminse, contains a great number of mucous glandules, while 
a great abundance of mucous follicles or lacunae open on its free 
surface. Outside of the elastic or cellular coat, there exists a 
spongy texture, which is erectile to a certain extent. The lower 
or pelvic extremity is embraced by a quantity of muscular fibres, 
that seem to be continuations of the anterior portion of the sphinc- 
ter ani muscle, and constitute a true sphincter for this vulvo-ute- 
rine canal. 

At its outer extremity it is attached to the os pubis, by its ante- 
rior and lateral margins, whereas its posterior and lateral margins 
are attached to the perineum and labia pudendorum. Its upper 
end embraces the cervix uteri, which, filling that end of the tube, 
makes there a cul-de-sac. In front, it is attached to the bladder 
and urethra; behind, it touches the rectum, and is soldered to 
that gut, by the recto- vaginal septum, for about its middle third 
part; its upper third part, resting on a peritoneal investment, and 
its lower third answering to that pyramidal perineal tissue that 
lies betwixt the anus and the posterior and exterior extremity of 
the tube. On each side, the vagina corresponds to the cellular 
tissue inclosed within the ligamenta lata. 

If you carry a curved trocar into the upper part of the vagina, 
close to the womb, and then turn its point forwards and upwards, 



ABSENCE OF VAGINA ITS RELATIONS. 85 

and thrust it through the part, the point will enter the bladder, 
and open it, — lower down, and near the outer end, the point will 
wound the female urethra. 

If you carry the point high up, and near the womb turn it back- 
wards, and thrust it, you will cut into the peritoneal sac ; an inch 
and a half lower down, the rectum will be pierced; and still 
lower down, the tissue of the perineum will receive the point. 
Turn your trocar sideways, and push it towards the ischium, it 
might be possible to drive the trocar to the plane without wound- 
ing anything but cellular tela, and the levator ani. 

Pray take care to keep these things in mind in all your operations 
here, whether with the bistoury, the crotchet, the forceps, or the 
cautery. They will guide you, both in diagnosis and in practice. 

The vagina, like all living tissues, is subject to various mala- 
dive affections springing from all those causes that can produce 
inflammation, and its sequelse; such as blows, wounds, contu- 
sions, over-distention, long pressure, foreign substances, and poi- 
sons, whether animal, or of other sorts. You will occasionally 
encounter cases in which, being consulted for your professional 
opinion, you discover that nature has failed to develop the 
vagina. 

For example, I have now under my care a young woman, who, 
upon attaining the age of puberty, did not become regular, as her 
mother had reason to expect. Instead of perceiving the men- 
strual discharge, she was at stated intervals of about a month, 
attacked with severe pain in the hypogaster and loins, which, 
after tormenting her for several days, left her in pretty good health, 
to return again as usual, at the end of a month. The mother, 
when I was called, informed me that some sort of obstruction 
existed in the passage ; and I was accordingly permitted to ex- 
amine the parts by inspection. The girl was slender, weighing 
from ninety-five to a hundred pounds; about sixteen years old, and 
well developed in every particular, save that there was a cul-de- 
sac of the vagina, terminating less than one inch from the os mag- 
num. There was a hard tumor to be felt jutting upwards, above 
the plane of the superior strait, like the womb of a woman at 
quickening; but it was hard and solid — not soil and compressible. 

No access of exploration of this tumor could be had by way of 
the vagina, which, as I said, was a shallow blind sac. 

By introducing the finger into the rectum, the tumor could be felt, 



86 ABSENCE OF VAGINA. 

presenting the same characters of hardness as above the strait, and 
the whole tumor was of a pyriform shape, like a developed womb of 
four or five months. Introducing a sound into the bladder, and 
carrying the right indicator into the rectum, it was easy, by press- 
ing the point of the catheter against the finger, to explore the 
parts inclosed betwixt them ; and thus to ascertain that the vagina 
positively failed at the bottom of the cul-de-sac. 

You might here ask how I know that the vagina failed in its 
development, and that there was not some fine and delicate aper- 
ture and canal leading up to the womb and connecting the w T omb 
with the outer genitals. I should reply that I think a cautious 
examiner could hardly be deceived by his senses as to the presence 
or absence of a vaginal tissue between the point of the finger and 
that of the sound ; and, as I could discover no such tissue, and as 
I know that cases of total failure are met with now and then, I 
have confidence in the certainty of my tactile perception. 

But there was one great uncertainty in relation to the case. I 
mean the uncertainty as to the nature of the cause that rendered 
the virgin's womb as large as that of a woman at quickening- 
time. Of course, I could not but presume that it was distention, 
and that such distention could arise only from the collection within 
the womb, of the products of repeated menstruations having no 
way of escape. 

I consulted, for the benefit of the patient, that distinguished 
surgeon Dr. Jacob Randolph, who, after a careful exploration of 
all the points of the case, agreed with me in opinion, that it might 
be possible that the uterine extremity of the vagina might not have 
failed ; and in such case, the pudendal could perhaps be con- 
nected with the uterine extremity of the canal by means of an 
incision. 

Dr. Randolph introduced a strong sound into the bladder, and 
gave me the staff to hold firmly, while with the left indicator in the 
bowel, he drew the bowel as far off as possible towards the sacrum, 
in order to separate the bladder as widely as he could from the 
gut — for, please understand, that we both conceived there was no 
tissue of the nature of a vagina betwixt them. 

Prepared in this way, the surgeon, by means of strokes with 
his bistoury, which he directed from side to side, while the labia 
were strongly diducted in order to expose the bottom of the cul- 
de-sac, succeeded in carrying a deep incision accurately between 



ABSENCE OF VAGINA. 87 

the bladder and the rectum — without wounding either ; of which 
there appeared great risk and probability. Dr. R., however, did 
not find any uterine portion of a vagina, although his incisions 
were so deep that he could nearly bury the whole fore finger within 
the wound. Seeing at length, that there was no hope of estab- 
lishing a communication with the mouth of the womb in this 
manner, he brought the operation to a close. Introducing a silver 
bougie of near three inches in length, and one in diameter, to the 
bottom of the incision, he maintained it for several weeks in the 
artificial vagina thus prepared. This was done in the hope that 
the blood, supposed to be contained within the enlarged womb, 
might, by some process of absorption of tissues, find its way into 
the artificial canal, which was a probable expectation. This 
expectation utterly failed, however. 

After many weeks, the periodical sufferings of the young woman 
being not only renewed, but attended with augmented intense- 
ness, with Dr. Randolph's approbation, I pushed a moderately 
small curved trocar and canula quite into the central nucleus, if 
I may say so, of the womb. Upon withdrawing the style nothing 
came away through the canula, save a few drops of blood, so that 
I failed also, in this attempt. Yet I had the satisfaction to find 
that the wound made by the trocar was not followed by any disa- 
greeable consequences, nor was the operation painful. 

You will find upon consulting that fine work of Mr. Thomas 
SafFord Lee, " On Tumors of the Uterus and its Appendages ," 
that Mr. Lee, at page 8, has the following paragraph : 

" Tumors of the womb are insensible. This statement at first 
appears startling, when we are aware that sensibility is one of the 
surest tests of their presence, when projecting into the cavity of 
the womb; but this sensibility depends upon the covering of the 
uterine cavity, which it receives in its descent. The tissue of the 
tumor itself is entirely deprived of nerves : I have seen a sharp 
pointed probe introduced some inches into its substance, without 
the patient feeling anything beyond the first prick through the 
sensitive nervous membrane." 

Do you ask me, then, what is the nature of this tumor ? — I have 
to answer, that I do not know. It has not sensibly increased in 
size for the last three years, the girl is still in pretty good health, 
though she still is the subject of periodical pain, which is kept 
within bounds by the proper use of anodynes. The artificial 



OS CONGENITAL NARROWNESS OF VAGINA. 

vagina has disappeared, and the parts have returned to their con- 
genital form. 

I say the case is a mysterious one. I am sure it is not a case 
of distention, for I know that my trocar entered the very centre of 
the mass ; and that any collected menses it might have contained 
would have flowed out through the canula. I repeat, that I do 
not understand the nature of the tumor ; but I have reason to 
suppose it consists of a solid mass of tissue, essentially of the 
nature of womb-texture, but, in some respects, hypertrophied 
and heterologue. 

You will readily concur with me in the supposition, that were 
it a tumor from distention by menstrua, the uterus must by this 
time have acquired an enormous size, — this not being the case, 
allows me to form only the conclusions above stated. 

For another case of absence of the vagina, I beg to refer you 
to " Colombafs Treatise on Diseases of Women," in which you 
will find, at page 119, the account, by me, of a sample in which 
the vagina was wanting as well as the womb itself. I shall not 
quote it here. Mr. Colombat gives at page 107, many cases of 
absence of the vagina ; and at 108 relates, with details, a case 
treated by Dr. Stolz, of Strasburg. I must also refer you for these 
cases, which I prefer to do, as Colombat's work is everywhere 
accessible, and, moreover, so complete as to fulfil all one's reason- 
able wants of information as to the surgery of these affections. 

The instances of congenite absence of the vagina present per- 
haps but small grounds of hope as to the induction of a truly 
natural and healthy state of the organs by chirurgical means. 

Not so, however, as regards the congenital narrowness or con- 
striction of the canal. 

I have met with instances of females in labor, in whom the 
vagina was so narrow, as to admit only with force, the fore finger in 
the taxis. Such a case was that, which I have stated, in Colom- 
bat. I well remember my surprise at the difficulty of making 
examination of the labor in that lady's case, and I cannot now 
believe that the sexual act could have been properly consum- 
mated, notwithstanding she was pregnant, and in labor. 

I have also consigned, in the same volume, the history of a 
case of narrow vagina that was presented for my opinion in the 
year 1843. This married lady, whose vagina was not larger than 
a common silver probe, was cured without risk, and with very 



TO DILATE STRICTURE OF VAGINA. 89 

little pain, by the simple process of gradually dilating the passage, 
in which she lost no drop of blood, and suffered no attack of in- 
flammation. 

I wish that you would take the trouble to reflect carefully for a 
few moments, on the power we possess to overcome constrictions 
and narrownesses, by means of sponge tent, bougies, and other- 
apparatus. You may perceive that a man with a urethra reduced 
for inches of its tractus to the size of a knitting needle, can in a 
few days of dextrous and gentle use of the bougie, have his ure- 
thra dilated to such a size as to admit the largest lithontriptor ; 
that the female urethra can be made to admit the index finger, 
the anus permit the whole hand to enter the rectum, and the va- 
gina give escape to a child of twelve pounds avoirdupois. Such 
reflections ought to convince you that the congenrte narrownesses 
and constrictions of the vagina ought not to be treated with the 
knife, but with the dilater. You should also remember the rela- 
tions of the vagina on its sides and at its upper extremity, so as 
to reflect on the danger of wounding the peritoneum, or establish- 
ing in it a diathesis of inflammation, which, once begun, is not 
easily checked ; and which, in fact, has been not rarely found to 
follow operations on the vagina, which it has caused to end in the 
death of the victim. 

My counsel herein, is that when you shall be consulted for 
these maladies, you clearly explain the nature of the case — the 
modes of cure — their differences, and the time probably required 
to effect that cure; so that no disappointment or vexation may arise 
to embarrass you, or prevent your success. 

A linen bougie can always be made to take the place of a 
probe, and you can augment the size of your cereoles from day to 
day. Half a yard of fine linen dipped in very hot white wax, and 
coated, furnishes cere-cloth, out of which you can cut pieces of 
suitable size to be rolled up into cylindrical or conical forms. 
In the cities there are always silversmiths who can manufacture 
for you light bougies of silver, from a quarter to two and a half 
inches in diameter, which being galvanically gilt, last for a long 
time, and are exceedingly convenient and portable; the smaller 
ones sliding inside of the larger ones, like a nest of pill boxes. 

I must offer you one caution on this head. Take the example so 
often presented in labors, of the dilatation of the parts, not by one 
resolute and unintermitted thrust, but by successive and long in- 



90 DILATATION OF THE CONTRACTED VAGINA. 

termitted impulses. So, in the dilatation of the constringed vagina, 
keep in view the law of its dilatation in labors, which is done by 
a succession of efforts, with very considerable pauses or rests 
between each effort; do not endeavor to hurry the operation, 
therefore, but be satisfied to get on, however slowly; festina lente 
is the motto. If you go too fast, you will excite irritation or in- 
flammation, which must be cured before you can go on again. If 
you go on slowly and gently, there will be perhaps some sense 
of soreness left for a while after each dilatation, but it will not 
rise to the height of inflammation, but leave the parts soft, ductile 
and humid, well prepared for the next attempt. 

How often will you repeat these attempts? Once a day; not 
oftener; and it will be better occasionally to allow two days to 
elapse, provided there be reason to dread an irritative or inflam- 
matory engorgement as the sequela of the last attempt. 

Don't leave your patient imperfectly cured; by so doing you 
expose her to danger of death in any labor that might follow the 
cure of the stricture. Dr. Brainerd, Illinois Med. and Surg. 
Journ., May, 1844, states a case in which the woman lost her life 
in labor by rupture of the vagina, which gave way, rather than 
allow of the dilatation of a stricture which had succeeded the 
second of two antecedent labors. 

I advise you to look to a case that was published in 1712, in 
PHistoire de VAcademie des Sciences, p. 35, and which I find 
quoted in Dr. D. D. Davis' great work on Obstetric Medicine, t. 
i. p. 102. The case was related by M. Antoine de Mery sur seine : 
the end of a goose-quill could scarcely be forced into the vagina. 
It was not until ten years of married life that she conceived, and 
bore a son without harm or danger. I am sure any one of you 
would, in such a case, by means of cereoles, save the patient such 
ten years of suffering. 

Let me again refer to Colombat for an account of the method I 
used in curing a case of contraction, by means of two longitu- 
dinal segments of a cylinder, which, being introduced separately, 
were afterwards strained asunder, by means of wooden cylinders, 
the size of which, small at the first operation, was larger at the sub- 
sequent ones. I have given a drawing of those cylinders, and the 
segments at page 97 of Colombat on Diseases of Females. 

I shall say no more here as to the congenital contractions of the 
vagina, under the belief that what I have already stated and re- 



IMPERFORATION. 91 

ferred to, is sufficient for awakening your attention to the nature 
and cure of the evil. 

The tube is subject to closure by imperforation of the hymen; 
and by cohesion of its surfaces. 

The most common of these atresias, is the case of cohesion of 
the sides of the vagina taking place in consequence of inflamma- 
tion brought on by labor : the imperforate state of the membrana 
hymen, is less frequently met with, at least I have had reason, dur- 
ing my professional life, to adopt this opinion from my own obser- 
vations. 

The words imperforation, atretism, occlusion, obturation, and 
cohesion, express, in fact, the idea of a closure of the canal, 
though you apply the terms imperforation, obturation, and occlu- 
sion, chiefly to the cases connected with faulty development of 
the hymen. 

It is very improbable that the state of imperforation of the 
hymen will be ascertained to exist, until the age of puberty comes 
to expose the young woman to the consequences that follow the 
accumulations of menstrual excretions in the inner part of the 
vagina and womb. 

The lateness of this discovery is a matter of some surprise, if 
we advert to the constant secretion of mucous fluid from the geni- 
tal mucous membranes; since it is difficult to conceive what be- 
comes of all that is formed from childhood up to the fourteenth or 
fifteenth year. It must, of course, be removed by the absorbents; 
yet it would a priori seem improbable that so considerable a pro- 
duction could be taken up by the absorbing vessels. Such is 
the fact, however, that the imperforate girl is commonly not dis- 
covered to be so, until the menstrual age, and then she is affected 
with all the signs of menstruation, save the show. 

Suppose the young woman should have thirteen menstruations 
in the course of the first year, and produce only three ounces 
each time, the sum of the several productions would amount to 
thirty-nine ounces or nearly two pounds and a half. Of course, 
the whole accumulation would not reach so high a figure, because 
the thinner parts being continually absorbed, the remainder is 
reduced in quantity and becomes thicker and more and more vis- 
cid, from the admixture of mucus and epithelium. But it must 
happen that at length, the vagina being overfull, the womb itself 
will enlarge or expand to receive the new monthly contribution. 



92 IMPERFORATION. 

Be not surprised, in such a case, to rind the girl suspected of 
gravidity, nor be misled to confirm such a suspicion by discover- 
ing that the mammary glands sympathizing with the womb, are 
developed as in gestation, and that they even proceed so far as to 
secrete a portion of milk. The mammary gland may be regarded 
as a life dependent of the womb, participating in its varying states, 
whether in pregnancy or in disease. It is a fact that cannot be de- 
nied, that where the womb becomes augmented in volume, in the 
amount of its sanguine circulation, of its innervation, its absorp- 
tion, &c, the mammse sympathise with it, and they may form the 
milk, whether the change in the uterus proceeds from pregnancy, 
or from some other cause. 

This is a case in which, from inexperience, you might be prone 
to run into error. Take heed, therefore, not to pronounce your 
opinion until, by all possible means of making it sure and clear, 
you feel enabled to speak with confidence on the case. Men of 
the highest professional rank have been, through careless or hasty 
diagnostical conclusions, led into the greatest perplexity; and 
some have thus ruined forever the fairest prospects of fortune and 
reputation. It is always a cause of mortification and regret to 
the brethren, when any one of their class brings discredit upon 
all, by exhibiting his own incompetency, whether through igno- 
rance or want of circumspection. Be ever mindful, then, that your 
errors and misconceptions redound, not to the hurt of your patient 
alone, but to your own shame and defeat, and the lessening of the 
authority and happy influence of all the members of your. body. 
Those are the truest friends of the profession, who honor it by 
their intelligence and probity. Such persons render medicine an 
honorable pursuit. 

I have had one invaluable rule of action for many years past, 
which has served me so faithfully, that I shall tell you what it is. 
When a female comes to me to complain of failure of the cata- 
menia, I scan as rapidly as I can, the state of her great vital 
functions, in order to discover any lesions or implications of them 
in her malady. That is to say; I observe her respiration, her cir- 
culation, and her general innervation. In using these words I mean 
to express not only the idea of a certain number of respiratory acts 
per minute, or so many pulsations of the heart, or the vague and 
abstract idea of nervousness ; but I mean all the physiological de- 
pendence and results of the oxygenating function of the lungs; the 



IMPERFORATION. 93 

nutrient, calorific, and colorific action of the circulation, and the 
equableness and spontaneousness of the nerve power, as evinced 
in the countenance, gesture, station, and motions of the patient. 
When I can thus discover no signs of ill-health, I am at once 
aroused to the suspicion of gestation. But, a man must be a fool, 
who, in such delicate concerns, should breathe his thought ; this 
is, of all cases, the case where one's left hand ought not to know 
what the right hand doeth. 

Let us suppose now, that a young person who ought to men- 
struate, but has never yet changed, should call upon you for coun- 
sel on account of a swelling and pain, or uneasiness in the region 
of the pelvis, yet exhibiting no signs of disease beyond these now 
specified. What can you say, what do, what know? Is there 
any therapeutics for an unknown case? You can do nothing, nor 
know nothing, and you ought not to say anything, except, that 
you do not understand the nature of the malady, which it is, more- 
over, impossible to know without the taxis. 

Now, this is a terrible decision to come to, as far as the poor 
patient is concerned; but it is not your fault that she is unfortu- 
nate in being so situated. If she will suffer the proper inquiry to 
be made, there can be little doubt of the ability to procure the 
information, and you cannot undertake to cure until you know T 
what is the matter. Let them call a midwife, whom you can in- 
struct as to the visit she is to make ; or if none such can be found, 
you can offer your own services for the occasion. 

Suppose the people connected with the case, are persons of 
sense and discretion, I am very sure they will refer the matter to 
your judgment, and you will make the proper exploration your- 
self. 

Instead of finding the os uteri, you discover a cul-de-sac, just 
within the os magnum ; and probably, it will present an exterior 
convexity, with fluctuation behind it. You place your hand on 
the hypogaster while she lies on the back, and you discover 
with the palm or fingers, the hemispherical fundus of the womb 
jutting quite above the plane of the superior strait. If you press 
it downwards, the convex bottom of the cul-de-sac becomes more 
protuberant, and you cause a fluid to fluctuate betwixt the fingers 
of the right and left hands. 

Still unsatisfied in your opinion, you press an index finger into 
the rectum, and then find the pelvis filled, or nearly filled, with 



94 IMPERFORATION. 

a vaoina and uterus evidently turgid with fluid, contained within 
their walls. 

Now you have a clear ground to speak. The case is one of 
imperforate hymen; a case of atresia vaginae. The remedy is to 
destroy the obturating membrane, and that is to be done by thrust- 
ing a trocar through it, while a finger in the rectum gives you a 
clear notion of the direction to be given to the trocar, the bladder 
having been first evacuated by means of a catheter, in order to 
make sure of that organ being quite out of harm's way when 
the trocar is pushed through the membrane : the rectum should be 
also emptied by means of an aperient enema, so as to leave not 
the least reason to dread any injury to parts not intended to be 
wounded by the trocar. If I were about to perform such an ope- 
ration, and the patient should say, "I have just now made water 
freely," I could not feel justified to plunge the trocar into the sac 
upon such a representation. I should never deem any one a pru- 
dent surgeon, who should do so until the catheter had proved the 
matter beyond doubt. 

Do not expect to find the membrane no thicker than the page 
you are reading. It is very thick and strong. I have seen one 
not far short of a quarter-inch in thickness. When your trocar 
is withdrawn, and the detained menstrual fluid evacuated, pass a 
narrow straight bistoury with a probe point, through the opened 
membrane, and cut it into four triangular flaps ; carrying the in- 
cision nearly down to the level of the vaginal walls ; and once in 
two or three days, press through the opening thus made, a silver 
gilt bougie of proper size, so that, when the cut edges are healed, 
they may not leave a constriction of the vagina, to expose the 
patient to danger of laceration, should she ever be placed in cir- 
cumstances of labor. 

You may be consulted for a case like this. A married lady, 
married five years, in beautiful bloom of health, suffered periodical 
attacks of pain coinciding with her menstruations. 

The menstrua flowed very slowly, and with difficulty and pain ; 
the discharges black, viscous, and stinking. They continued 
many days, but when they were over she was well again. I cannot 
say that her health, in any essential degree, had suffered from this 
state of things, for she was strong and exhibited a very perfect 
embonpoint. 



IMPERFORATIOF. 95 

Accompanied by her husband, she came to Philadelphia and 
placed herself under my care. 

She assured me that, though she menstruated, she was many 
days going through with the elimination, and that all the menstrual 
blood that escaped, was very dark, often granular, and always 
quite offensive. 

In a strong light, the patient lying on the back, I found a shallow 
cul-de-sac, the bottom of which was the hymen, in which I in vain 
sought to find any opening. There was not even a pore to be dis- 
cerned, nor could a probe, that I pressed against every point of the 
hymen, detect the smallest opening in the surface. I was obliged 
to desist from further researches, advising her that at the next men- 
strual period, near at hand, I should probably be enabled to detect 
the orifice from which the flow might escape, and asking to be in- 
formed as soon as the appearance should present itself. 

After a few days, I was invited to attend ; and upon placing 
the parts in a good light, and pressing against the bottom of the 
cul-de-sac a speculum with a large opening, so as to put the 
membrane strongly on the stretch, I again was for a long time 
baffled, for I could not observe any signs of the menstrua, though 
she repeated she was unwell, and in her usual manner. 

I felt the whole superficies again with a probe ; at length, I 
observed a small dark point and supposed it might be caused by 
the menstrual fluid passing forth. I pushed the probe against it, 
but it would not admit it. I next took a very fine one, fit for 
the puncta lachrymalia, and it passed quite through the hymen 
into the vagina, and when I withdrew it, there followed a drop of 
blood of the menstrua. 

Finding now, that I had obtained access to the upper cell of 
the vagina, I forced a larger probe and then a very fine pointed 
bougie, and so a larger one until I dilated the pore sufficiently to 
pass up a narrow probe pointed straight bistoury, with which, I 
cut the membrane into flaps, and then passed two fingers to the 
os uteri. She discharged a good quantity of menstrual fluid. 

The subsequent treatment consisted in the daily introduction, 
by her hand, of a metallic short bougie, until the passage was 
rendered complete. 

I suppose that the- hymen in this case was one-quarter inch in 
thickness, firm, and fleshy ; and yet you see, the lady had men- 



96 COHESION OF VAGINAL WALLS. 

struated all her life through a pore, not larger than the pimctum 
lachrymale ; nay, not so large. 

I used all this care, because I found the resistance so great. In 
a complete case of imperforation, with accumulation of menstrua 
above, the membrane would have been convex and fluctuating, 
and I should have opened it at once with a trocar or bistoury; 
but here I thought it more prudent to explore the part as I did, 
before I should venture to cut upon it. 

I have nothing further to say as to vaginal atresia, caused by 
imperforate hymen. The books are full of such cases, which 
present very little of interest, save that arising from the necessity 
of being careful in the diagnosis. There is no difficulty in the 
treatment, either by the trocar or bistoury or the point of the 
finger, where the membrane is thin. 

There are great numbers of cases of this affection published in 
the books. Of these, Dr. Davis has made a collection, and 
printed the* references in his first vol. pp. 108-9. The whole 
matter is so simple, and so easily understood, and readily treated, 
that I shall not cite them for you, but merely refer to the pages 
of the Obstetric Medicine in which they are found. 

You are aware that the vagina may become occluded after 
labor, by the cohesion of its surfaces. This is a consequence of 
inflammation, and probably of traumatic or wound-formed inflam- 
mation. 

The accident takes place in some persons through very violent 
and distressing attacks of inflammation, which may, or may not 
be attended with sloughing. Or on the other hand, a woman who 
has given birth to her child without any extraordinary delay or 
difficulty, shall suppose all to be well with her, until the month of 
purification being over, she discovers upon returning to her hus- 
band's bed, that an obturation exists rendering her imperforate. 

Again, a woman shall be attacked with ulceration of the lip of 
the os uteri; which being neglected, invades the whole vaginal 
cervix of the womb, and descending upon the walls of the vagina, 
may become an ulcer nearly as large as the palm of the hand. I 
have seen one, which, examined by means of a speeulum uteri, 
exhibited such dimensions. This is not a malignant ulcer; but it 
is very difficult to cure ; for when you have reduced it to be not 
larger than the face of a shilling, it shall, perhaps, in the course 
of two days, recover its ancient dimensions. In this ulcer, I have 



COHESION OF VAGINAL WALLS. 97 

picked off from the surface large patches of what appeared to 
be thickened epithelium or exudation membrane. Some of the 
patches that were brought away by a dressing forceps, were large 
as half a dollar. Now an ulcer of this kind will hardly ever be 
found to heal permanently, until it has contracted the tube to an 
exceedingly small diameter, and then, when the canal is almost 
obliterated, it heals — or what cures it as completely, the surfaces 
cohere, which puts an end to the ulceration. The cohesion is 
easily overcome. 

A young woman gave birth to a large child, and got well with- 
out any trouble, or supposing that anything was wrong with re- 
gard to the genitalia. After the month was out, it was discovered 
that she was affected with total atresia, or vaginal imperforation, and 
this without having had the least reason to suppose that anything 
was wrong with her. Of course the obturation must have taken 
place at a late period in the month, since, had it happened early, 
the lochia must have accumulated above the coherent points. 

When she came to me I found no aperture whatsoever in the 
shallow cul-de-sac at the bottom of the sinus pudoris. 

It was evident, on inspection, that the orifice of the vagina was 
puckered or crimped, and quite closed by cohesive inflammation. 
I in vain endeavored, by diducting the opposite sides of the cul- 
de-sac, to bring into view any small aperture ; nor could I dis- 
cover any by means of a probe, which was pressed upon all 
the different parts of the surface. The atresia was complete. 

I took a strong probe in my right hand, and stretching the 
points of union with the thumb and medius finger of the left, I 
drew the bulb of the probe along the line of the cohesion, and 
found that it gave way just as happens in the same operation for 
cohesion of the labia, or prepuce and glans, in children. By means 
of successive strokes of the probe, upon the line of cohesion, I 
found that at last, the probe had passed through the obstruction 
into the upper cell of the vagina. I next dilated the constricted 
parts with the index finger, then with a cereole, and at last with a 
metallic bougie, and sent her home, without causing the loss of 
twenty drops of blood, and with very little pain or inconvenience 
of any sort, in the cure. I advise you, that whenever you may 
be able to restore parts to their natural form and state, without the 
use of a cutting instrument, you should prefer such method, since 
it is true, that every wound when healed, leaves the tissue 
7 



98 ULCERATION OF THE VAGINA. 

changed, whereas a part cured without a wound recovers its truly 
normal form and properties. 

I attended a lady in her confinement in the month of April, 
1845. She was subsequently attacked with metro-peritoneal 
fever, and after great sufferings and risks, was found to be in a 
convalescent state, save that she had a retroversion of the womb. 
For this, she was treated with pessaries: in 1846, she was often 
complaining of debility, and discharges per vaginam of an un- 
healthy character, for which she would by no means be prevailed 
upon to submit to a vaginal examination, on account of her fasti- 
dious delicacy. At length, in the autumn of 1846, she submit- 
ted to a more particular inquest into her condition. 

She was frequently attacked with the most cruel pains in the 
interior of the pelvis; which, also, extended up as high as the 
umbilical region, producing the greatest intolerance of contact, 
and a dorsal decubitus, with great flexion of the lower extremi- 
ties, the least motion of which augmented the pelvic and abdo- 
minal pain to an insufferable degree. The pulse was frequent, 
and of a hectical character. The stomach was affected with almost 
incessant nausea, and frequent vomitings of glairy mucus. The 
bowels were constipated. The patient was much reduced in 
strength, and emaciated. 

The taxis at first gave me great alarm, as the roughness and 
hardness of the upper portion of the vagina gave me reason to 
suspect a carcinomatous degeneration of the organ. 

I learned, by inspection, with the speculum of Recamier, that 
the os, and the vaginal cervix were covered with an ulcer which 
extended upon the vagina. The surface of this ulceration was 
overlaid with a thick and unattached pseudo-membranous deposit 
of lymph, that I could pick off in scales of an inch square with 
the dressing forceps. It was in all respects like the croup mem- 
brane, or other diphtheritic deposits, which you will find in the 
throat in scarlatina, in ptyalismus, &c. As the speculum was a 
pretty large one, I could by passing it to the upper extremity of 
the vagina, not only examine the ulcer there, but in slowly with- 
drawing it, I could observe the whole character and extent of the 
vaginal ulceration. 

Now I am sure that the superficial extent of the ulcer could not 
have been less than six or seven square inches. 

I had a great deal of trouble with it. It was soon reduced to a 



ULCERATION OF THE VAGINA. 99 

superficial size of one inch ; and then broke out again to its ori- 
ginal extent, in the course of a few days. • I made use of injec- 
tions of honey of roses, containing fine extract of cicuta suspended 
in it. I painted the whole surface with a brush dipped in a solu- 
tion of nitrate of silver. I repeatedly whitened the whole surface 
with my nitrate of silver pencil. She took corros. chloride of 
mercury dissolved in compound syrup of sarsaparilla; and after- 
wards, hydriod. of potassa, in the same vehicle. 

The ulcer was at last most tractable under delicate contacts of 
acid nitrate of mercury, and finally healed up entirely, leaving the 
lady free from pain, and in good health and spirits. But, it 
should be observed, that this dreadful ulcer did not heal without 
contracting the walls of the vagina, so that for the upper third of 
the tube, the quondam seat of the ulcer, there is now a cylindri- 
cal vagina, about the size of this quill with which I am writing. 

Please observe that the contraction of the vagina was an eco- 
nomical process, inasmuch as the smaller it became, the smaller 
was the surface to be healed; and I doubt much, whether it could 
have healed at all, had the surfaces been kept constantly extended. 
I am not sorry for the result, since I have, 1st, the consolation to 
find my patient cured of a dangerous and painful disease ; and 
2d, to know that, with the bougie and the cereole, I can very rea- 
dily cause the vagina to receive its pristine amplitude, without 
risk or pain. I should be the most imprudent of men, were I to 
attempt the dilatation until a considerable lapse of time shall have 
allowed every vestige of ulcerative propensity to disappear ; 
since, to dilate the contracted vagina at once, with the cereole or 
the metallic bougie, would be very apt to awaken the old malady 
a^ain. 

The sensation communicated to the finger by the examination 
of this case, was so similar to that produced by the taxis in car- 
cinomatous vagina and cervix, that I think I should have been 
misled, had I confided for my diagnosis to the sense of touch 
alone. I beg to advise you to resort to the speculum in all cases 
where your diagnosis is obscure. 

I do not regard the vagina as a fibrous tissue, but rather, as a 
mere mucous membrane. That is to say, a true corpus mucosum, 
with papillae, and epithelial delimitary surface ; with mucous fol- 
licles, and abundant provision of muciparous glands. Such is the 
structure ; but, this essential structure is surrounded and limited 



100 VAGINITIS. 

or backed by a condensed cellular sheath containing muscular 
fibres, arteries, veins, capillaries, nerves and absorbing vessels. 

It seems very reasonable to suppose that such a compound tissue 
as this, should be the subject and seat of many various maladies 
arising from various causes and forms of inflammation, hypertrophy, 
infiltration, weakness, and utter relaxation. 

Like the air passages it is liable to aphthous disease, and like 
them, to the various states of catarrh; like them, also, it may be 
attacked with diphtheritic inflammation or plastic inflammation ; or 
the whole structure, mucous, vascular, and cellular, may be the 
seats of the most painful inflammation, proceeding to a height 
transcending the power of recovery by effusion, by resolution, or 
by adhesion, and terminating consequently in gangrene and mor- 
tification. 

You will feel, I am sure, no surprise to learn that labor is often 
followed by inflammation, not merely mucous ; but inflammation 
deserving to be called a true vaginitis, in which the whole organ 
is implicated. 

It is equally obvious that the vast distension of the tube by the 
child, must, in certain instances, lay the foundations of vaginitis, 
in which not the tube only, but the bladder, the urethra and rec- 
tum are, to a certain extent, and sometimes to a dangerous extent, 
involved. 

These post-partum inflammations are scarcely more apt to be 
formed after long and tedious, than after very rapid labors ; and it 
is reasonable to conclude, that, when a child is forced into the 
world by one or two labor pains, in a labor lasting not beyond 
five or ten minutes, the dilating tissues must suffer a greater and 
more unnatural violence, than where the slower and gentler yielding 
of the textures allows them time to unfold and dispart, without 
rupture or laceration. My own experience certainly leads to the 
conclusion, that a labor of ten minutes is more likely to be fol- 
lowed by vaginitis than one of twenty-four hours. 

You ought also to take into consideration the effects of long 
continued pressure of the vagina against parts of the pelvis. For 
example, in a labor where the forehead of the child rests upon the 
top of the right ischial plane, whilst its vertex is jammed against 
the middle or lower portion of the left ischial plane, and continues 
to impinge for hours upon the same points under the throes of 
a powerful womb, it seems almost miraculous that the compressed 



VAGINITIS. 101 

tissues of the vagina do not invariably slough after the labor is 
ended. But the fact is, they not only escape sloughing, but they 
in a great majority of such cases do not even inflame ; or at least, 
not to such an extent as to excite complaint, or communication 
of complaint to the accoucheur. 

The pressure of forceps; the jam of the exterior curve of crot- 
chets, and sometimes the ploughing up of the textures by the 
point, or rupture, are among the causes that excite vaginitis. 

Again, vaginitis is often extremely painful when provoked by 
gonorrhoea. In these instances, the extension of the inflammation 
behind and below the mucous tissue brings the whole vagina into 
a state of suffering, just as happens in the gonorrhoea of males, 
where, from intenseness of the inflammation, the corpus spongiosum 
urethras becomes affected, producing painful chordee, which is a 
true urethritis. 

Vaginitis is characterized by sensibility, pain, heat, discharge 
of mucus, or of sangui-mucous excretions; by thickening of the 
mucous membrane ; narrowing of the canal ; by inflammatory 
exudation on the mucous surface ; a sense of weight in the pelvis ; 
micturition; aching in the sacrum and loins, andatenesmic state. 
The color of the tube is heightened, and I have observed that the 
orifices of the mucous crypta are elevated and surrounded by 
bright areolae. 

The case should be verified by the use of a small conical specu- 
lum of Recamier, the uterine extremity of which should be cut 
obliquely at about 45°. This speculum being oiled with olive 
oil, not lard, should be carried to the cervix, and then by withdraw- 
ing the cone, every superficial inch of the vagina can be examined 
as the speculum is slowly withdrawn. By this method, gentle- 
men, you can be perfectly sure of your diagnosis. 

In an intense vaginitis, there will be constitutional disturbance ; 
as rigors, with febrile reaction, and all the phenomena presented 
by the constitution under provocation by an inflammation of so 
important a structure. 

"Where fever is present, and no circumstances of the general 
health absolutely forbid it, you ought certainly to commence the 
treatment by enjoining, first, absolute rest in bed, with the shoulders 
very low; and second, a free venesection; third, a mercurial or 
saline purgative dose ; fourth, frequent vaginal injection of tepid 
mucilages ; fifth, anodyne enemata of the rectum ; and sixth, as 



102 VAGINITIS. 

soon as the constitutional disorder is somewhat on the decline, to 
lave the inflamed surface with solution of nitrate of silver. 

Ten grains of the salt dissolved in an ounce of water, or twenty 
grains if occasion be, should be prepared. A large camel hair 
brush, such as is called here a throat-brush, dipped in the solution, 
can be freely applied by the beveled speculum, rotated as above 
mentioned, to all the parts on which the contact is desirable. 

This is the best plan, but, w T here your patient is fastidious and 
foolish, you can perhaps, though not so well, attain the object, by 
using the salt in solution, injected by means of the new glass- 
vaginal- syringe. 

In intense inflammation of the vagina, eight or ten American 
leeches may be applied directly to the surfaces, by the speculum. 

I think there will be found few samples of vaginitis to resist 
such a treatment, properly administered. 

Where the cure, however, lingers, you should repeat the vene- 
section, and make persevering use of the mucilaginous injections 
of the vagina. Dover's powder in doses of three to five grains 
may be given every four or six hours, but not to the exclusion of the 
anodyne enema at night. At the close of the case, astringents 
w T ill be called for; and they may consist of weak solutions of 
Goulard's extract of lead with watery solution of opium, or with 
extract of cicuta suspended in the fluid of injection. 

As to the contacts of nitrate of silver, I am of opinion they ought 
not to be repeated beyond once in every twenty-four hours, and I 
prefer the solution as above, to the nitrate pencil ; because, though 
less powerful, they are more manageable, and may be recurred to 
more frequently than the contacts of the solid salt. 

I shall trouble you with no further remarks on vaginitis, except 
to say, that where your case of inflammation transcends the power 
of recovery of the tissues, you must expect to find the sloughs 
coming slowly away, and that you should favor their separation 
and escape by means of injections of castile soap and water; by 
small bits of fine sponge soaked in soap-suds, and held in the 
speculum forceps, and applied through the speculum, handled 
most gently. In all such cases, pray beware to hinder the forma- 
tion of a perfect atresia of the tube, which you can do, by daily 
carrying the index finger, soaked in very warm water and lubri- 
cated with castile soap or with oil, quite up to the os tineas : you 
cannot find a more proper or less painful bougie. In the closing 



INVERSION OF MUCOUS MEMBRANE. 103 

of the ulcers, if any prove perverse, you should aid the cure by 
thus carefully cleansing them, and then dressing them with honey 
of roses containing extract of cicuta. For this purpose, soak a 
long narrow plumasseau of lint in the solution, introduce it in situ 
through the speculum, which being slowly withdrawn leaves the 
dressing in contact with the ulcerated surfaces. 

The vaginal mucous membrane may become enormously thick- 
ened. In this case it protrudes beyond the vulva, and projecting 
more and more, comes at last to make a tumor as large as a stout 
man's arm ; at the bottom, or most salient extremity of which, is 
found an opening, circular in shape, through which you can 
thrust your index finger up to the os uteri, which you will find 
inside of, or above, the anterior plane of the perineal strait. 

The exterior surface of this great mass is dry if it have been 
long down ; and it is surrounded by horizontal corrugations or rings 
like the rings of an annelide. In fact, I have seen the exterior 
surface assume very much the character of the derm or skin, in a 
woman seven months gone with child. It went easily up beyond 
the sinus pudoris by gentle pressure ; but came down again as 
soon as the pressure was removed. A globe pessary two and a 
quarter inches in diameter, would keep it up while the patient was 
in a horizontal posture. But, she found such a posture inconve- 
nient in her circumstances, and preferred the prolapsion of her 
vaginal mucous membrane to the pessary, — so she laid it aside. 
At length she fell into labor, during which the prolapsed mem- 
brane retired spontaneously, and the delivery was easy and safe. 
This was more than three years ago, since which she has had com- 
paratively but little trouble from her disorder. 

At St. Bartholomew's Hospital, in London, I saw a similar 
case, in which a tumor nearly as large as the festal head at term, 
had resisted many efforts at reduction. I was pleased to see Mr. 
Lawrence apply his hand to the reduction, which he accomplished, 
after some three minutes of effort. This was in May, 1845. 
Such reposition, I presume, is always possible. The difficulty 
lies chiefly in the want of knowledge as to the manner of doing 
it. But, one leading point in that matter, is to push it in the 
true direction. To thrust it against the pubis, would be to tail ; 
so would it be to thrust it against the perineum. It should be 
returned coincidently with the axis of the vagina. 

I shall not, in this letter, speak of vaginal leucorrhoea, I 



104 VAGINAL FISTULA. 

purpose to treat of leucorrhoea under the general head of the 
uterine disorders, though I am aware that the vaginal and uterine 
discharges are very different from each other. 

For the same reason, I shall not here speak of carcinoma of the 
vagina. 

Of vesico-vaginal fistula, I have little to say. It is better that 
the account of that frightful accident given by M. Colombat 
should be referred to. In that account you will obtain all the 
requisite information, and as I have laid it before you in my trans- 
lation of his invaluable work, I shall hold myself here excused 
from entering on any discussion of so painful a subject, as well 
as that of the recto-vaginal fistula, which, though not so distress- 
ing as the urinary fistula, is yet a frequent source of disgust, and 
a constant one of disquiet and unhappiness. Pray read especially 
the extraordinary case described by Dr. J. Rhea Barton, which I 
there reprinted. That distinguished surgeon, by an operation 
altogether new, relieved and perfectly cured a most distressing 
case. It was originally published in the American Journal of the 
Medical Sciences, for August, 1840. I might have mentioned the 
case while I was speaking to you on the affections of the labia 
perhaps, but as it also appertains to the vaginal maladies I shall 
refer to it in this connection. You will find it in Colombat, p. 263. 

Doubtless the successes obtained by the various methods of 
treating vesico-vaginal fistula, consigned in Colombat's volume, 
are cheering — but, I fear that where a considerable loss of sub- 
stance has taken place, there is little hope of a cure — and you 
will find on inquiry that Mad. Boivin and Dr. Duges are equally 
despondent as to the cure of any considerable apertures in the 
bladder itself. I cured a very small one, by touching the orifice 
with nitrate of silver — it was in the cul-de-sac of the vagina to 
the right of the vaginal portion of the cervix uteri. 

There is less difficulty when the leak is in the urethra — and 
particularly do I think so, since I witnessed an admirable opera- 
tion by Professor Pancoast, about a year ago, for the restoration 
of the canal of the urethra, which had been opened by a slough, 
produced by the protracted pressure of the foetal head, in a lady 
from a distant state. In this case there was an incessant drib- 
bling of urine from the orifice of the fistula — it ceased not, day nor 
night. 

The urethra, when examined by the touch, was about as large 



TAGINAL FISTULA RECTOCELE. 105 

as one's little finger. That part of it which led to the meatus 
urinarius was contracted par defaut d'extension, and required to 
be dilated with a bougie. 

Jn order to make the vesical communicate again with the 
vulvar half of the urethra, Dr. P., with a small sharp pointed bis- 
toury, made a deep incision in the vesical half, which incision 
penetrated parallel to the canal of the urethra; and laid the tissue 
open from the right, quite over to the left angle of the gap. He 
next pared off the mucous lining of the vulvar surface of the gap, 
and cutting it into a wedge-like shape, thrust this wedge betwixt 
the lips of the upper incision, dovetailing, as it were, the lower 
into the upper one. This pared wedge, being in contact with the 
fresh surface of the incision or slit, and being maintained there 
by the skillful application of several stitches, while a catheter kept 
up the calibre, union was produced, and the lady left the city, dis- 
charging all the urine again through the true meatus urinarius. 
I did not think, at the time of her leaving Philadelphia for her 
home, that she had perfectly recovered the voluntary power over her 
bladder — which was owing probably to injury of its sphincter by 
the labor. She, however, no longer had the constant dribble of 
urine, and to a certain extent could control it, several ounces often 
collecting before she was compelled to yield to the urgent call to 
discharge it. If she failed so to yield, the urine escaped involun- 
tarily. 

More than twenty years ago I was consulted by a lady who 
complained of what she supposed to be descent of the womb. 
She had a sensation, not very painful, of distention of the genital 
fissure, and of something pressing itself out from the labia, near 
the inferior commissure. Upon exploring the case by the taxis I 
discovered a roundish soft tumor which consisted of the posterior 
wall of the vagina, which was protruding like a knuckle of 
intestine in hernia, from the sinus pudoris. I told her it was a 
protrusion of the vagina and rectum, and that it was distended 
with gas. I advised that the bowels should be kept in a soluble 
state, and that great attention should be given to obviate costive- 
ness, and particularly accumulations of feces in the rectum ; 
that the tumor was a vaginal rectocele, and that it would cure 
itself if she would be careful upon the points suggested. She 
was so, and has never had any trouble with it since, I have 



106 VAGINAL RECTO CELE. 

met with the case in several different individuals, since the one 
now mentioned. 

You can have no difficulty in verifying the diagnosis, if you 
will condescend to introduce the index finger into the rectum, 
and bending it forwards, press it into the pouch-like cavity which 
constitutes the vaginal tumor, behind which the finger will ap- 
pear, having passed over and above the perineum in a forward 
direction. 

In all cases, where you are called upon to make an examina- 
tion of the rectum, you can, by pressing the pulp of the finger 
towards the vagina, push it forwards towards the os magnum — 
thus producing a temporary vaginal rectocele, which vanishes 
upon withdrawing the finger. In the old chronic and neglected 
relaxations of the part, there is formed a true and permanent 
pouch, which does not wholly disappear, even when the rectum 
is completely evacuated. 

M. Malgaigne, in the " Memoir es de VAcad. Roy. de Medecine," 
1838, states that he had met with the first sample of the accident 
eighteen months before, say in 1836, and appears disposed to 
claim, at page 487, all the credit of having discovered the 
novelty.' 

" It may seem strange," says he, " at the present brilliant epoch 
of surgery, to see quite a new malady take its place on the file 
of external disorders, and which, though not rarely met with, may 
be as easily understood by the examination of the practitioner as 
by the scalpel of the anatomist. I have been enabled to maintain 
a pretension to its discovery ; for among the numbers that usually 
spring up to contest such claims, there has not been a single 
claimant for this one. All the classical treatises ; all the collec- 
tions of cases published in France, from the days of Mauriceau 
down to the period of Madame Boivin and Dr. Duges, are silent 
on this subject. The same silence is maintained by Scarpa in 
Italy ; by Richter and Chelius in Germany ; and by Sir Astley 
Cooper and Mr. Samuel Cooper, in England. But after much 
research I have discovered some mention of the disorder in those 
authors, who seem not to have been as explicit in their descrip- 
tions as is desirable." 

M. Malgaigne then cites a passage of Sabatier, from his 
memoir on displacements of the womb and vagina, in the 3d vol. 
Mem. Royal Acad, of Surgery, in which the protrusion of the pos- 



VAGINAL RECTOCELE AND ENTEROCELE. 107 

terior wall of the vagina is fully attributed to the relaxation in- 
duced by habits of costiveness. 

Dr. Monteggia, of Italy, says he, confounds the accident with 
procidentia of the vagina, while Dr. Clarke, of London, supposes 
that the relaxation of the wall of the vagina permits it to fall 
downwards, drawing the rectum with it. 

Now, I wish you to observe, that this vaginal recto cele is a 
true rectocele, that is, a disorder of the rectum, and not a disor- 
der of the vagina, for you cannot deny that, were the rectum to 
preserve all its natural strength, no such protrusion could possibly 
occur. Indeed, I have on several occasions had the opportunity to 
observe, that in what is called impacted rectum, there is no vaginal 
rectocele. In impacted rectum, we find the whole excavation of 
the pelvis filled with faeces, as it is filled with the head or trunk 
of the child, in labor. The child in labor spreads out the vagina 
equably, towards the bony wails of the excavation of the pelvis; 
whereas, in impaction, the impacted faeces within the rectum in 
like manner spread out the rectum towards the bony walls of the 
pelvis, filling it and jamming it full, with many pounds weight of 
the residuum of digestions. Now, in these impactions of the rec- 
tum, we have no vaginal rectocele; because, though the rectum is 
enormously distended, it is equably distended while in the vaginal 
rectocele, only the anterior wall of the rectum gives way by re- 
laxation, pushing the feeble tube of the vagina before it. Hence, 
when you wish to cure vaginal rectocele, your indication is to 
cure the rectum, which being cured, the vagina will also be cured, 
or rather, restored to its natural form. The vagina is not in fault. 

The vaginal rectocele is not a large tumor; it is as large as 
a walnut, or as large as an egg. 

I repeat, that to cure it, the state of the rectum is to be chiefly 
regarded; it is to be prevented from becoming overloaded. 

If the patient should be annoyed, however, by an extraordinary 
relaxation of the tissue, one so great as to allow the protrusion from 
a collection of mere flatus, you may expect all the disorder to 
disappear upon introducing into the vagina a conveniently pro- 
portioned pessary, whether a globular or elyfroid one. 

While I am on this subject, I beg to call your attention to a 
case of vaginal enterocele, of which I published a description in 
the Examiner, edited by Prof. Huston of the Jefferson College. 

The case occurred September 26th, 1844, in a person in West 



108 VAGINAL ENTEROCELE. 

Philadelphia, who was in labor of her fifth child, under care of 
Dr. Bicknell. She had always had very easy rapid labors. I ar- 
rived at two o'clock, P. M. She was attacked at twelve o'clock, 
the niffht before ; and was now fourteen hours in labor. I found 
her in violent labor pains, and she also complained of intense 
pain and soreness at a point in the right iliac fossa. 

I could not reach the child's head without keeping my finger 
close to the symphysis pubis, for my finger was pushed in that 
direction by an immense vaginal enterocele ; consisting of a great 
mass of intestinal convolutions, which, falling down below the 
brim of the pelvis, so completely filled up the excavation, pushing 
the back wall of the vagina towards the bladder, that the child's 
head could not possibly engage in the strait. The tumor was soft, 
though to a certain degree tense. I had scarcely explored it before 
I recognized its true nature ; and waiting, therefore, until a labor 
pain had ceased, I kneaded it upwards w T ith my fingers, after 
having first thrust the head upwards a little. It began to move, 
and following its ascent with my fingers, it fairly flew up into the 
cavity of the belly; the next labor pain which immediately fol- 
lowed the escape of the prolapsed convolutions upwards, nearly 
brought the head through the superior strait ; the succeeding one 
pushed it into the excavation ; after which, two other pains com- 
pletely expelled the child, which was a large one and in good 
health. Now here is a case in which the posterior wall of the 
vagina was thrust over towards the pubis, by a double handful of 
intestine, nearly strangulated by the superincumbent pressure of 
the foetal head in labor; as soon as the pressure of the convolutions 
was taken away, the vagina was no longer disordered or displaced, 
and the same, I imagine, will be the case in the vaginal entero- 
cele, whenever you shall obviate or prevent the pressure of the 
rectum forwards. 

It is not to be denied, that the posterior wall of the vagina, or 
rather its mucous coat, may be the subject of engorgement, infil- 
tration, and ultimately of such a degree of relaxation, as to allow 
it to prolapse even through the sinus pudoris ; but that case is 
very different from the case of descent of the whole mucous tissue, 
w T hich I have described in a subsequent part of this letter. It is 
not a vaginal rectocele. 

You should be careful to observe, that in some desperate cases 
of retroversion of the womb, the posterior wall of the vagina may 



VAGINAL CYSTOCELE. 109 

• 

be thrust forward even so far as to escape from the genital fissure, 
by the posterior face of the womb pushing it out into sight. I 
shall shortly cite a very celebrated case of the kind, that occurred 
at Lausanne, and was described by Dr. Maior. 

Small, solid tumors, depending from an ovarium, or developed 
within the ligamenta lata, may also cause protrusions in the same 
direction. 

The very antithesis of the vagiual rectocele, is the vaginal cys- 
tocele, or protrusion of the anterior wall of the vagina, by a pouch- 
like enlargement of the lower and posterior part of the bladder 
of urine. You will verify your diagnostic here by introduc- 
ing your catheter, or a sound into the bladder, and directing the 
point dowmwards into the tumor, where the point of the catheter 
is felt by the finger in taxis. 

This is a fault of the bladder, and not of the vagina. This is 
clear, since the bladder contains the urine, and not the vagina. 
If the bladder gives way in relaxation, the whole vesico-vaginal 
septum must yield ; but it is a cystic malady, and not a vaginal 
malady. 

The tumor is soft, and disappears upon emptying the bladder, 
as a general rule; yet you may well suppose that a case may have 
been so chronic, and so neglected, as to give rise to a permanent 
pouch, which will not disappear, even when every drop of urine 
has been withdrawn by the catheter. 

It gives in general little pain, and is only annoying by the 
sense of distention, or that disparting feeling that arises upon the 
protrusion of the sacculus through the labia pudendorum. 

The woman should be directed to discharge the urine frequent- 
ly; and if incapable of that, to make use of a catheter, which 
she can readily be taught to introduce with her own hand ; a thing 
far less disagreeable than to submit to the catheterism by the hand 
of the surgeon. 

I have made it a rule in all such cases, to introduce a globe 
pessary, of suitable diameter, whereupon all complaint has ceased. 
The tissues thus supported, recover their tone in the course of a 
short time, and then the pessary may be withdrawn. 

It is necessary I should inform you, that vaginal cystocele — 
or at least a tumor temporarily deserving to be so denominated — 
occurs now and then in labor, and interrupts or totally prevents 
the accomplishment of the delivery until it is removed. This is 



110 CYSTOCELE DOUBLE VAGINA. 

a case where, from unequal or non-coordinate action of the fibres 
of the urinary bladder, those of the bas-fond yielding to the dis- 
tending pressure of an accumulated urine, the anterior wall of 
the vagina is thrust backwards against the posterior wall, and both 
of them pushed towards the hollow of the sacrum and the peri- 
neum, by the presenting part of the child. 

In this case, the child's head cannot enter the excavation, while 
that excavation is filled with urine contained in the bas-fond of 
the bladder. It is the antithesis of the vaginal enterocele that I 
encountered at West Philadelphia. 

To make the diagnosis and the cure at one and the same time, 
you have only to introduce your catheter, well curved, directing 
its point downwards and backwards, into the tumor. The point 
of the catheter may be felt by a finger in the vagina, and it will 
be found, that, as the urine escapes, the tumor is resolved and 
withdrawn, whereupon the child's head can enter the excavation 
of the pelvis. 

I subjoin the account of three cases of double vagina, which I 
submit without additional remarks, taking them from the Medical 
Examiner of December, 1846, in which they were first published. 
The account serves sufficiently to explain to you the nature of 
such a conformation of the parts, and the degree of inconvenience 
likely to attend it. 

On the — October, 1846, I was called to Mrs. , aged 

20 years, in labor of her first child. She is a remarkably well 
formed and comely woman. 

The pains were sharp and frequent, evidently of the kind called 
dolores prseparantes, or grinding pains. After some time, as they 
had become more violent, I examined the state of the os uteri, 
which was of the size of half a dollar, the head of the child pre- 
senting, and the ovum unruptured. In the course of an hour more, 
I examined again, and the os uteri was then nearly dilated. While 
pressing the palp of my index finger to the left side of the pelvis, 
it caught in a seeming bridle, which at the instant made me fear 
the cervix uteri had been broken, so as to detach a semicircular 
portion of the os uteri, for the pains had been exceeding sharp, 
and their returns had been announced by violent cries. It was 
but a moment that I indulged the idea of a rupture of the cervix, 
for upon pushing the index farther, and flexing the finger, I found 
I could draw the point of it outwards, pulling along with it the 



DOUBLE VAGINA. Ill 

bridle in question. Still I did not understand the case until, hav- 
ing withdrawn the indicator, I examined with it the structure of 
the external parts, and then learned that the lady was possessed 
of a double vagina. Supposing that such a revelation would not 
be agreeable to her, I kept my own counsel, hoping that the child's 
head would come down through the right or the left channel with- 
out injuring the septum. But after the head escaped from the 
circle of the os uteri, the bridle or partition would not go defi- 
nitively to the left or to the right, although I thrust it first one 
way and then the other. The tie was so strong that the fleshy 
septum extending from the anterior to the posterior columna of the 
vagina, would not admit of the dilatation of the lower or outer 
third of the tube. And as the lady was very strong, and had 
powerful uterine pains, I began to perceive some danger of the 
vagina being ruptured by the vain efforts for expulsion. 

I now explained to the monthly nurse, and to a relative of my 
patient, the cause of the delay and the necessity that had arisen. 
I therefore procured the requisite permission to expose the parts 
to an inspection. Upon this, the two orifices of the vagina were 
seen to be exactly alike, and the partition stretched across the 
head from front to rear of the passage, which by it w r as wholly 
preventing from dilating. 

I now with a strong scissors divided the wall by a single stroke 
of the instrument, whereupon the child's head advanced, dilated 
the os magnum, and was speedily delivered with safety to both 
the mother and her infant. She never complained afterwards 
relative to the operation, and within a month I met her on foot in 
the streets. 

A week later, I was called to a lady in her 30th year, in labor 
of her first child. Upon examining the state of the os uteri, I 
found the circle not much bigger than a quarter dollar, with thin 
margin, and within it the penis of the child; the scrotum being- 
detected within the os uteri after the pain ceased. As it was night, 
I went to another apartment and slept an hour, when being called, 
I found the os uteri very much dilated, and a buttock, near which 
was the right foot, presenting. 

While inquiring into the state of the cervix, I hooked my finger 
into a bridle, just as I had done in the case above mentioned, and 
I confess that the same thought was obvious to me, viz., that she 
had broken off a half ring of the circle of the os uteri, but I im- 



112 DOUBLE VAGINA. 

mediately afterwards discovered that I had another case of double 
vagina under management. In this case the partition was very 
firm and thick, extending from the os magnum almost up to the 
os tincse. I inspected the external structures, and the two va- 
ginas were each perfect and alike, included within labia pudendi 
common to both. 

I was glad to find that only one foot of the child would come 
down, being fearful that if both should descend, I might not rea- 
dily prevent one from entering the right and the other the left 
vagina. 

I now disengaged the right foot and brought it down the right 
channel ; the left leg was flexed upon the belly and thorax of the 
foetus. With a little assistance the foot was delivered, and the 
buttock of the child coming downwards, thrust the vaginal wall to 
the left, and so the trunk was delivered. I had great difficulty to 
extricate the head of the child, which remained long in the va- 
gina ; the infant breathing from time to time the air that I admit- 
ted through the hollow of my hand and fingers to its mouth and 
nostrils. The child, a male, was alive, and is in good health; 
the mother is quite well recovered. 

Some years ago I was called by the late venerable Dr. Ruan to 
consultation upon a case of double vagina in a primiparous wo- 
man. I delivered the child with the forceps through the right 
canal, without difficulty or any injury, and had some five weeks 
later an inspection of the parts, which, as I remember, were very 
similar to those described in my second case above. 

Farewell, gentlemen; I shall adjourn to my next letter some 
remarks upon the nympha?. C. D. M. 



COHERENT NYMPHSE AND LABIA. 113 



LETTER X. 

LABIA AND NYMPHS-COHERENT. 

Gentlemen: — In my 8th letter, I laid before you some obser- 
vations upon the accidents that happen to the nymphse, after hav- 
ing spoken of their physiological nature. In the present commu- 
nication, I have to offer further remarks upon those tissues. 

They are frequently found to cohere in very young children ; so 
as to cover up the small triangular superficies lying in front of the 
symphysis, and which you studied at the dissection, under the deno- 
mination of Vestibulum. This triangular space, you remember, 
is bounded above by the clitoris, on each side by the nymphse, 
and below, by the crown of the pubic arch; or in other words, 
by the upper semi-circumference of the os magnum: — near its 
lower edge is the meatus urinse. 

A young baby is usually clouted, or to use a gentler phrase, 
diapered. In case its mamma is not scrupulously nice, the diaper 
is often left too long unchanged, and the irritating salts of the 
urine come at last to irritate and vex, and finally to inflame the 
mucous surfaces that are too continually bathed with it. 

A very gentle inflammatory diathesis being in this way acquired 
by the mucous tissue, whose opposing surfaces are kept in con- 
tact, union or fusion of surfaces is likely to take place ; and at 
length, the mother makes the discovery. 

When this gentle adhesive inflammation sets in, as to the 
nymphse, it is also almost sure to be established as to the labia 
majora; of which, after all, the nymphse are but folds, or rugae of 
the labia. I have many times found the labia coherent, without 
cohesion of the nymphse. Indeed, the latter are much less likely 
to become glued than the former, because, when the lower sec- 
tions of the labia become fused or soldered together, there is 
nothing to tear them asunder — whereas, at their upper section, 
there is the repeated issue of a stream of urine, which is of suf- 
ficient force to break up a commencing process of the sort ; and 
so it happens that, we do not find cohesion of the labia to extend 
above the level of the meatus urinarius as a common occurrence. 
8 



114 COHERENT NYMPHiE AND LABIA. 

M. Colombat speaks of a case in which the nymphse cohered 
in such a fashion as to cover up the orifice of the meatus and 
compel the urine to ascend behind the cohering apron, in order 
to escape, with difficulty, and dribbling, over the genital surfaces. 
They were separated by an incision, which relieved the child of 
her dysury. 

Dr. Duges, also, in the introduction to a Pract. Treat, on the Bis. 
of the Uterus and Appendages, p. 30, gives you the account of a 
little girl, whose urine escaped by a narrow orifice near the cli- 
toris. The catheter could not be introduced into the bladder 
from this orifice, but went into the vagina, because the labia were 
also coherent. Pray do not, however, believe what M. Duges 
asserts in the same place; viz., that cohesion of the nymphse 
necessarily accompanies that of the labia externa; I am sure you 
will find, in practice, it is not the case, except very rarely. 

It is to be readily concluded that, if a child, suffering from an 
occlusion, by this cause, of the genital fissure, should by neglect, 
or from excess of fastidiousness, be suffered to grow up, the 
fusion of the surfaces might become complete, and thus effectu- 
ally prevent the fulfilment of her sexual destiny as a parturient 
creature — for, the longer the union continues, the more complete 
will it become, and the more absolute the loss or extinction of the 
mucous structure, whose opposing faces first came into soldering 
contact. 

Whenever the fault is discovered — say up to the sixth or eighth 
year, and I have known it not to be detected earlier than the 
tenth year — the mucous membranes are not lost, but only coherent, 
and they may be pulled apart, leaving the newly uncovered super- 
ficies true mucous superficies, and not fleshy ones. 

The same sort of cohesion I have observed in the glans and 
preputium of a little boy. 

In all the cases that have fallen under my care, I have adopted 
the following method of cure. 

The child is held down on its back, on the nurse's lap ; who 
abducts the left knee with her left hand, while I abduct the right 
one with my right arm. Then, separating and stretching asunder, 
as far as I can, the labia with my left thumb on the right labium, 
and my index finger upon the left one, I draw the bulb of a 
common probe dipped in oil along the raphe, which it always opens 
and separates without bleeding ; or at least, without the loss of 



COHERENT NYMPHS AND LABIA. 115 

five drops of blood. The pressure of the probe appears to me 
to have the effect of pulling out a sort of villi, like a cylindrical 
epithelium, which had interlocked their floating extremities and 
become hypertrophied, like placentules in the sheep. 

M. Colombat advises, as a measure of precaution, after the divi- 
sion, to touch one of the surfaces, either the right or the left one, 
with the nitrate of silver; not to touch both of them. His notion 
is, that by touching one surface only with the nitrate, we institute 
in that surface a stage or a rate of vital action different from that 
going on in the one left untouched ; and as there is then no parity 
of vital movement in the two superficies, they will not cohere 
when they are brought into contact. 

I have not adopted his idea. But the idea is a very philoso- 
phical one, or rather a truly physiological one, founded on what 
is well known to be a fixed law in teratology. You would do 
well to study that beautiful law as it is laid down by M. Serres 
in his remarkable work, " The Anatomie Transcendantale" a 
volume which contains the richest stores of fact and reasoning on 
the nature and operation of the development forces in man. But 
to return to my subject : 

When I have completely destroyed the cohesion, I dip the 
minimus finger in oil, and draw it downwards to the four- 
chette, effectually separating the labia, and I then explain to the 
nurse the necessity of repeating this method once a week at least; 
as the mere separation of the cohering surfaces does not cure the 
cohesive tendency ; which, being in full force, will soon unite the 
surfaces again, and give other trouble, besides that of feeing the 
surgeon. The last motive is an aBgis for the baby: if you do 
not set it fairly before her, you may soon be called again to make 
it cry ; whereupon I advise you not to forget such a prophylactic 
charm. The last thing the sick think of is the doctor's fee; tell 
them of it and they sometimes take care of their health. 

While I was writing to you about the labia, I did not say any- 
thing as to their cohesion, because I wished to make my remarks 
on it in coincidence with those I should have to make on the same 
accident as to the nymphse, and now I have nothing more to offer 
on the subject worthy of your attention. 

The nymphse are occasionally the seats of a very rebellious sort 
of ulceration. I have found them at times very difficult to cure. 

In one example, the nymphae near their summit or angle, were 



116 ULCERATED NYMPHiE. 

deeply eroded, and the ulcerated surfaces were hard from the 
induration of the base of ulceration. The young person, about 
sixteen years of age, was not uncleanly in her person ; nor was 
her health positively bad, as being affected by any sort of consti- 
tutional vice, that I could discover. 

In this case I succeeded in effecting a cure by repeated con- 
tacts with strong solutions of sulphate of copper ; which, next to 
the nitrate of silver, appears to me to possess a great power to 
overcome ulcerative tendencies of the mucous membranes. It is 
reasonably to be suspected, in such cases as are not clearly to be 
traced to some constitutional depravation, that the local irritation 
is maintained by vicious propensities to excite the parts by fric- 
tion. On this head I would gladly refer you to the monstrous 
proceedings of a scoundrel under the garb of a physician, in a 
case related by the late David D. Davis, the able Professor of 
Midwifery in the London University College : you will find it 
at page 58, vol. 1, of his magnificent quarto on obstetric medicine. 
It ought not to be reprinted in this book. 

Should you encounter any cases that will not readily yield to 
contacts of your nitrate pencil or to a sharpened crystal of sul- 
phate of copper, you will scarcely fail to obtain healthy and 
healing granulations, if you should carefully, very carefully 
and delicately touch the ulcerated points with, a small camel- 
hair-pencil, whose point shall have been dipped in some acid 
nitrate of mercury. This escharotic cuts everything down like 
a knife ; and is not very painful, — but it is so powerful that you 
ought not to let it touch anything but the very points you design 
to affect. A jet of solution of soda, or salt of tartar, or of lime- 
water, upon the part after the contact, will neutralize all the 
excess of the acid that you may have incautiously left, and save 
the patient from the cauterization of other parts which you desire 
not to burn. A sponge filled with soap suds answers the same 
end, by neutralizing the excess of the acid. 

An enlargement of the nymphae to such an extent as to prove 
troublesome and offensive to the individual herself, might be 
safely diminished by the excision of a portion of the hypertro- 
phied mass. You will please to observe, however, as the tablier 
des Hottentottes is an ethnographical peculiarity, it does not neces- 
sarily follow that an unusual development of the organ must be 
the occasion of great trouble. The chief annoyance resulting 



EXCISION OF THE NYMPHS. 117 

from its great protrusion is likely to be an ulcerative tendency, 
obtained from the constant friction of it in walking, and against 
the dress of the female. Such a source of disorder is, however, 
not likely to prove lasting, since the mucous surfaces, when brought 
out and kept constantly exposed to the air and to attrition, 
become covered with a real cuticle, and gradually acquire the 
properties of the true dermal tissues. 

As the nympha is a very vascular structure, it might be ex- 
pected that the vessels would bleed freely upon an excision ; yet 
no difficulty could arise as to the suppression of hemorrhage from 
a part which, like this, could be readily compressed, as lying close 
to the top of the pubal ramus. 

Mauriceau gives, in his 174th case, an account of an operation 
on the nympha as follows : 

" July 25, 1676, I operated for the excision of the nympha, on 
a woman who begged me to do it for her ; because, as she was 
obliged to be much on horseback, she was put in pain by the 
friction of the organs, and also because such an indecence was 
displeasing to herself as well as to her husband." 

After cutting off both of the nympha? with his scissors, Mauri- 
ceau remained near her for an hour, in order to observe whether 
hemorrhage' might follow ; during all which time she lost only 
about four ounces. Finding her doing so well he left her, but 
was much surprised on returning in the evening to find that she 
had had repeated faintings ; and that she had lost between forty 
and fifty ounces of blood in the course of only five or six hours. 

Mauriceau says she soon recovered, and was subsequently con- 
fined under his care. The labor was with a shoulder presenta- 
tion, for which he turned. No inconvenience attended it, as 
relative to the absence of the nymphse, which, says he, " n'etoit 
utile que pour la decoration." What a curious old Frenchman! 

In my next letter I propose to speak with you of the organ 
called clitoris, as the subject of disease, and am very truly your 
friend and servant. C. D. M. 



118 CLITORIS, 



LETTER XI. 

THE CLITORIS. 

Gentlemen. — Blumenbach, in his Comparative Anatomy, says 
that " the clitoris is found more invariably than any other item 
of the external genitals in the mammalia, that it exists even in 
the whole of them, and is probably wanting in no other instance 
than in the ornithorincus. 

Kraus has a long article on its derivation from the Greek xuitogis 
from xXftw, claudo, I close or shut. 

It is a body lying upon the symphysis pubis, composed of two 
corpora cavernosa, similar to those of the male, but unprovided 
with any corpus spongiosum, or canal of the urethra. As it has 
no corpus spongiosum, it of course possesses no glans. It has, 
however, a prseputium, consisting of a preputial fold of the angle 
formed by the junction of the two nymphse at their upper extremi- 
ties; so that in fact, the clitoris is an organ that juts its point forth 
beneath the superior angle of the nymphse, and thus gets a hood, 
covering, or prepuce from them. 

Being embraced above by the fold of the nymphse, it is clear 
that when the nymphaB are drawn by any cause downwards, the 
point of the clitoris is depressed and thus more readily brought 
to touch any such body. 

It is endowed with the most intense erotic sensibility, and is 
probably the prime seat of that peculiar life power, although not 
the sole one. Burdach, Phys. vol. i, 224, says that the clitoris 
is in "some sort the organ of touch for the genital apparatus." 

The erotic sensibility does not abandon it wholly when old age 
or the change of life has converted the ovarian stroma into a non- 
germiferous texture ; nor even where the ovaria are totally extir- 
pated, either in women, or domestic animals. It is true, that the 
aphrodisiac nature attends upon the ovaria, as its prime source 
and sustainer, and is most perfect when they are in their highest 
state of health and power ; yet there is an unknown connection 
and relation of this power as resident in the ovaria, to the means 



CLITORIS. 119 

of exciting it as resident in the tentigo, myrtis, dulcedo amoris, 
or clitoris, and its congenerous tissues. 

The anatomical constitution of the clitoris shows it to be the 
analogue in the female, of the male parts; and it might well be 
referred to as justifying the idea, that in a certain stage of 
embryonal existence the future sex of the forming being is not 
ascertained; as it certainly is not ascertainable by any inspection. 

Should you reflect for a moment on the nature of the corpus 
cavernosum and find it here ; on that of the corpus spongiosum 
and find it in the nymphse which cover the orifice at least of the 
urethra ; on the prostata, shaped like a Spanish chestnut, which, 
according to De Graaf, you find again on the outside of the ure- 
thra, which, like the male urethra, runs through the prostate gland ; 
can you not believe that the uterus is itself a transmuted prostate, 
or the prostate an atrophied womb, and thus discover the analogies 
that are so strong betwixt the various portions of the reproductive 
organisms of both the sexes? Should you carry the comparison 
farther, would not you find the spermatic cords in the tubes of 
Fallopius, and the seminal glands in the ovaria, of which the tubes 
are in fact the efferent ducts? Lesser transformations than these 
take place in many of the organs during the embryonal life ; in 
proof of which I recall to your memory, my remarks in the lecture 
room on the morphological changes that take place in the develop- 
ment of the foetal heart. 

Like all the organical forms, that of the clitoris is liable to betray 
the generic law which should produce only the small pimple-like 
body that we discover in the well and naturally formed pudenda. 
It may become enormously large, so as to equal in size the con- 
generous organ of the male. A specimen of this kind is usually 
the subject of much stupid wonderment; and it is soon noised 
abroad, as a sample of that impossible thing in any high zoological 
grade, a hermaphrodite. 

The mistake is the more sure to be made, if peradventure the 
labia participate in the faulty excess of development force, and 
come to bear, as they do, a strong resemblance to the male scrotum; 
in which case Martial's epigram on the Tribad Bassa seems appli- 
cable. 

" Mentiturque virum prbdigiosa Vpjms." 

There is a very curious and most interesting work, by Parent du 



120 ENLARGED CLITORIS. 

Chatelet, entitled De la Prostitution dans la ville de Paris, a work 
■written in a truly laudable and missionary spirit. M. P. du C. 
devoted immense labor of research among the thousands of Pa- 
risian females abandoned to that wretched life, with a view to 
ascertain the measures best calculated to promote not only their 
own reform, but the advantage of public morals. In his re- 
searches he addressed himself to every practicable source of in- 
formation. He says, at p. 121, 

" According to Mess. Jacquemin and Collineau, and the phy- 
sicians of the Dispensary, there is in the public women of 
Paris nothing remarkable as to the appearance and dimensions of 
the clitoris. There are found among them, as among all married 
women, certain varieties as to this part ; but nothing remarkable. 

"As these women are regularly examined, agreeably to a rigor- 
ous police ordinance, at stated intervals, their condition is well 
known; and yet, out of the thousands who are kept under such 
constant surveillance, there were only three in whom the organ 
was possessed of a notable excess of size. In one of these three, 
the clitoris was three inches long, and of the size of the indicator 
finger. 

" It was probable, not certain, that this girl had no uterus, as 
none could be ascertained to exist. She declared herself to be 
equally indifferent as to males and females ; and that she had 
abandoned herself to such a course of life, not from an excess of 
libidinous propensity, but solely as a means of escaping from the 
pangs of hunger." 

Parent du Chatelet does not believe that the other two women 
were specially urged by libidinous desire to enter on their aban- 
doned course. He declares that all three of them were utterly 
free from any signs of beard, which he looks upon as a trenchant 
characteristic of the male. The one particularly specified above, 
had no appearance of mammary development. 

M. Louyer Villermay, author of the article Nymphomanie, in 
Diet, des Sci. Med. Sub. Voce., relates a case from the Ephem. 
JYatur. Curios., in which the organ in question was equal in size 
to that of the male. The salacity of the individual had been ex- 
treme, from an infantile age. She died in child-bed, non dum 
satiata, like the Empress Messalina, or Cleopatra. The metro- 
maniac was the dominant force throughout her life. 

I presume it is not requisite that I should take the trouble to 



HERMAPHRODISM. 121 

point out cases of supposed hermaphrodism, in order to convince 
you that the conjunction of the two sexual natures in any highly 
organized animal, is a zoological impossibility : wherever nature 
makes the attempt, she fails ; producing a horrible confusion of 
organs, from which no effective function can possibly proceed. 

Mr. John Hunter's celebrated Observations on certain parts of 
the Animal Economy, contains a paper on the Free-Martin, from 
which you may learn that " when a cow brings forth twins, one a 
bullock, and the other to appearance a cow, the cow-calf is unfit 
for propagation, but the bull-calf grows up into a very proper 
bull. Such a cow is called in this country, (England,) a Free- 
Martin, and is commonly as well known among farmers as either 
a cow or a bull." 

The Free-Martin offers no attractions to the male, who never 
takes the least notice of her. The Free-Martin never breeds, has 
the bellow of the ox, and as a stall-fed animal resembles the ox 
or spayed heifer; being readily fattened, and possessing a tender 
and fine-grained flesh. 

Mr. Hunter having procured one of these animals, found the 
external genitalia in all respects feminine, perfectly formed. But 
the vagina terminated in a cul-de-sac, a little above the urethra, 
from whence the vagina and uterus were impervious. The re- 
motest extremity of the uterus terminated in two horns; at the 
termination of these horns (the Fallopian tubes), were placed the 
testicles, instead of ovaries. In another specimen, he found both 
the ovaria and the testes at the end of the cornua of the womb. 

You might, perhaps, feel inclined to object to me that, if both 
testes and ovaria were found here, the animal was truly herma- 
phrodite. It is a dangerous thing to doubt John Hunter's ob- 
servation ; and it is a sort of daring I should scarcely venture 
upon ; — but, in the present instance, I think if you will look at 
his paper, you will agree with me that Mr. Hunter's observation 
is incomplete, and that he is himself obliged to argue the point 
in favor of his inference. At all events, I see nothing in the 
paper to shake my firm reliance on the inevitable tendency of 
generic force ; and hence, I can place no reliance on human, nor 
any other mammiferous hermaphrodism. The idea is a poem in 
itself; but the prayer of Salmacis, that her lover's body and her 
own might be resolved and combined into a single one, and which 
is the highest culmination of the sentiment of love, is a prayer to 



122 ENLARGED CLITORIS. 

be granted only by the fantastical and freak-loving gods of the 
mythological host ; the Ruler of the world, whose laws are what 
we call Nature, never departs from that course in which there is 
no variableness, nor shadow of turning. 

But let us consider what are the maladies likely to obtrude 
themselves upon our attention, as affecting the part under con- 
sideration. Ulceration, hypertrophy, and enlargement, and ex- 
cessive augmentation of the libidinous desire. 

I deem it not necessary to offer any special remarks upon the 
management of its ulcerations, which should be treated upon the 
same same plan as similar ulcerations of the nymphaB, which are 
always likely to accompany it. 

The hypertrophy is most likely to be congenite. If it take 
place during a maturer period, it can be readily excised; probably 
the only remedy, and not called for, except when great inconve- 
niences attend it. 

Dr. Merriman describes one that was amputated in Dublin ; — 
it equaled, in size, a child's head two years old. There is in St. 
Bartholomew's Hospital, a specimen preserved in the Museum, 
constituting a mass of two inches in diameter, composed of a 
firm, pale, obscurely fibrous substance, traversed by glistening 
bands. The interior contains a number of cavities or cysts, filled 
with groups of small bodies attached by pedicles to their walls. 
For the above, I am indebted to an interesting volume published 
in 1847, under the title, " On Tumors of the Uterus and its Ap- 
pendages," by Thomas Safford Lee, M.R. C.S.E. &c, 8vo., 
London, pp. 222. I hope to present you some further citations 

of this very excellent writer's passages in the course of these 
letters. 

I pray you to advert to the very curious case of disease of the 
clitoris, which I published in Colombat's work, and about which 
I spoke to you at some length last winter. In that instance, the 
tumor was a globular body appended to the superior part of the 
genital fissure, and consisted of a clitoris, which in a gradual 
progress of morphological transformation continued during fifteen 
years, had become equal to the cubic content of twenty-two ounces 
of fluid blood, or mensual excretion. I have often had my feelings 
of surprise renewed, upon reflecting on the possible conservation 
during so long a period, of a material like that in question; and I 
am confident that it must have participated in the nature of the 



NYMPHOMANIA. 123 

menstrua, and that no other organic material save a reproductive 
one could have preserved it so long unchanged. But as I have no 
intention to describe*the case and its treatment a second time in 
this volume, I shall merely beg you to refer to my account of it, 
and to the print, which gives a correct idea of its appearance. 

Probably, the most serious malady that can affect the clitoris, 
is that morbid sensibility of it which provokes to constant attention 
to the erotic stimulation. This is a malady, dangerous not to the 
health only, but to the morals of the sufferer; for the physical 
sense is, in some instances, able to overpower the moral sense, 
which it carries captive in its mad and brutal career of indul- 
gence. I think that nothing can be found more revolting, than 
the spectacle of a female under the full influence of a Nympho- 
mania. 

I have met with a few samples of this terrible malady in the 
course of my long experience, and I am thankful to be able to say, 
but few; and those, not of the greatest intensity. In one of the 
cases, which occurred in a thin brunette, aged only nine years, I 
learned, to my astonishment, that for months she had been in the 
almost constant constant habit of irritating the erotomaniac sense, 
by various methods of provoking its exaltation, while at school, 
on the form, or standing up in class, at church, at table, in the 
dining parlor, and more than all, upon retiring to bed ; so that it 
appeared, she was very rarely without the sexual sense in a 
highly exalted perception of it. Her health had become feeble, 
and from the most ingenuous and gentle of children, she had 
grown cunning, deceitful, and w T icked in disposition. 

I made vain efforts, through moral treatment, to awaken the com- 
punctions of shame and conscience, and to set in array the dictates 
of common sense, and the love of life and health. The affair 
became so threatening that it was necessary to examine the parts, 
which were natural in appearance ; I found nothing peculiar as 
to the sinus pudoris ; no change in the appearance of the nymphae 
or clitoris. 

I put the case under a severe course of purgative medicines, 
that were repeated for a long time, and rendered her thin and 
weak. I gave purgatives to the child in order to reduce her 
strength by diminishing the crasis of the blood, hoping that such 
a cooling operation might be followed by some diminution of the 
erotic excitement. 



124 NYMPHOMANIA. 

I also directed ten grains of nitrate of silver, dissolved in one 
ounce of water, to be procured. The solution was freely applied 
to the nymphse and clitoris for several successive days. The child 
declared she had abandoned her habit, grew fatter and stronger ; 
but at length confessed she had always continued in secret to ex- 
cite her sexual sense. 

She was finally sent to the country, when her health became 
strong, and I have reason to believe that she lost her frightful 
propensity upon the recovery of her health. What, indeed, is ever 
likely to render all the innervations natural and healthful, if a firm 
and solid health of all the other organs fail to conduct back to a 
normal state, an organ or tissue that has become disordered. 
Health, like mercy, is twice blessed, since it not only gives, which 
is blessing, but receives, which is blessing also. I am not, there- 
fore, surprised, when I learn that a case so distressing, recovered 
under the invigorating influence of fine air and exercise, which, 
by restoring the harmonious concurrence of the other innerva- 
tions, compelled those of the aphrodisiac tissues to come under 
the same law of harmony. It is probable that by reducing her 
strength by the course of purgative medicines, I did harm rather 
than good to my patient. And yet, it is possible, that by so re- 
ducing her before sending her to the country, she was enabled 
more speedily to recover under the more extensive assimilations 
that were required to bring her up again to her former weight. 

There should be in your therapeutical and hygienical purposes, 
as to the disorder under consideration, I think, a constant purpose 
to build up, as early as possible, the shattered edifice of the nerv- 
ous system by good air, and a nourishing, but simple and not stimu- 
lating diet ; by exercise, carried to the extent of turning off every 
excess of nerve power in the direction and activation of the muscu- 
lar system; by an almost constant presence; by new, innocent, and 
attractive trains of occupation and thought; and the employment 
of the ferruginous tonics and vegetable bitters, the shower-bath, 
cold hip-bath, sleeping under thin coverings, and doubtless, above 
all, the administration in the evening, of a full dose of opium by 
enema. I confess, I have had but little experience in the treat- 
ment of such maladies, and as those which I have encountered 
have gradually terminated by a restoration of the health, without 
other inconvenience than the suffering, the mortification, and the 
alarm of friends, I am inclined to hope that, with great prudence 



INVERTED BLADDER. 125 

and circumspection on your parts, you will always find in the 
resources of your education, those principles of medical prescrip- 
tion that may enable you to conduct your cases to a favorable 
end. As I, like you, have been officially admitted to the rights 
exercendi, docendi, et scribendi, quocunque rite vocatus fuerim, I 
am admonished by the condition rite, not to cite in these letters 
any of the numerous shocking cases that are, perhaps, too fully 
and unnecessarily set forth and detailed in the authors. 

The orifice of the urethra, though not a sexual part in strict- 
ness, yet it is to be so regarded in the female. It is, not rarely, 
the seat of diseases demanding your counsel, or your surgical 
ministry. 

Dr. John Green Crosse, of Norwich, England, whose works are 
well known and highly appreciated, sent me a small pamphlet 
lately, containing an account by him, of a case of inversion of 
the urinary bladder, which came forth at the orifice of the urethra, 
and made there a " tumor about the size and shape of a walnut, 
projecting visibly, at the external labia pudendorum. It was of 
a blood-red color, and somewhat granulated upon its external sur- 
face, so as to resemble a large strawberry; and the surgeon en- 
tertained a notion that it was a vascular tumor, which might be 
removed by ligature, on which account he requested me to in- 
spect it." 

Now, gentlemen, you will please observe that this tumor existed 
in a girl between two and three years of age; and that the highly 
respectable physician, a colleague of Mr. Crosse, mistook it for 
a vascular tumor, that ought to be cured by extirpating it with a 
ligature. If he had put on the ligature himself, without consulting 
with Mr. C, he would have cut off the child's bladder of urine!! 
See, then, how dangerous it is in physic, to jump at a conclusion; 
and beware of the advice so often reiterated in the lecture room, 
never to give an opinion, until you have an opinion to give, nor to 
enter upon an action until you have learned where it may end. 
Even after Mr. Crosse's first examination, the girl was in the 
greatest danger of losing her bladder; for just as the surgeon was 
about to put on the ligature, Mr. C. discovered both of the urethral 
orifices, and he then pressed the tumor back into the vulva, and 
continuing to push it, it retired upwards, along an opening into 
which, after the tumor had gone up, he could and did actually 
introduce his little finger, and carry it quite up inside of the blad- 



126 EVERTED URETHRAL MEMBRANE. 

der ; so largely was the urethra of the child dilated by the long- 
continued distending pressure of the inverted bladder on its walls. 

If the ligature had been put on, the child must have died. 

Mr. Crosse could never learn how long the inversion had lasted; 
he could only ascertain that it had lasted for a " considerable 
time." 

There was no relapse of the inversion, so far as he had learned. 

Dr. Murphy saw a similar case at Dublin, which was cured by- 
reposition. 

You will also meet with cases in which the mucous membrane 
of the urethra becomes hypertrophied and inflamed, producing a 
fiery-red tumor at the orifice of the urinary canal. This is attend- 
ed with much burning pain, and obstruction to the flow of the 
water. It may be cut off by passing a silver canula into the blad- 
der, and excising all the out-hanging mucous tissue, by a bis- 
toury; cutting on to the silver tube by a process like the first inci- 
sion in amputation. Or where the patient is afraid of the knife, it 
may be readily cut off by half a drop of acid nitrate of mercury, 
or a camel's-hair pencil, which destroys at contact. 

I will not, however, close this letter, without cautioning you 
not to shut your eyes upon many samples you must be destined 
to meet with, of incomprehensible maladies — maladies, however, 
that become perfectly intelligible to us, if we study them in the 
light lent to us by investigation into the nature, extent, and great 
power of that aphrodisiac or reproductive instinct, which, however 
disastrous and shameful its excesses, must be admitted to control, 
to a certain extent, a very considerable part of the motives and 
actions of men, and without the incitations of which, the entire 
scene of living nature would soon be blotted out, leaving the earth 
a howling and desolate waste. Very sincerely yours, 

C. D. M. 



DISPLACEMENTS OF THE WOMB. 127 



LETTER XII. 

DISPLACEMENTS OF THE WOMB. 

Gentlemen : — The uterus, as you well know, is situated be- 
tween the bladder and the rectum; resting on the upper end of 
the tube of the vagina ; attached in front, to the bas-fond of the 
bladder; held in situ by two ligamenta rotunda in front, which 
prevent it from turning over backwards in the direction towards 
the promontorium of the sacrum ; and, lastly, prevented from 
librating to the right or left, by the left and right ligamenta lata. 

It is easy, now, to understand, one would think, that if the 
vagina preserves its natural length, and if the round ligaments 
are neither too short, nor too long, while the broad ligaments are 
also in a healthful state of tension, there can be no displacement 
of the womb — for the womb cannot settle downwards in the pelvis, 
unless the vagina also settles down, by growing shorter — nor can 
it be turned over backwards, while the 'round ligaments are only 
two and a-half or three inches in length. Nor can it librate, and 
become oblique to the right, while the left broad ligament pre- 
vents it, nor to the left, if the right broad ligament be not relaxed 
and elongated. This is clear — and if it be clear, then it seems 
to me, that it might hardly be worth while to give you any further 
trouble in the way of indoctrinating you as to the deviations of 
the womb. But I have some plain remarks to make, that may 
possibly assist you in obtaining such clear notions, as to put it 
out of the question for you to be embarrassed in the treatment of 
such cases, and these remarks will be numerous. 

Prolapsion of the womb, commonly in the world spoken of as 
falling of the womb, and bearing down of the womb, is so frequent 
an occurrence in married women who bear children, and is 
attended with so much distress and vexation for many of them, 
that I am sure no man can long practice physic without being 
appealed to for counsel and relief in this form of disease. But, 
with just views of the pathology and the semeiology o( the case, 
there are few samples of it that may not be made to yield to a 



128 DISPLACEMENTS OF THE WOMB. 

judicious treatment, based on correct views of the state, of the 
affection. 

Let us speak, first, of prolapsus uteri — or falling of the womb. 

By this is understood a case in which the os tincse approaches 
too near the orifice of the vagina ; and the degree of the pro- 
lapsion might, perhaps, in strictness, be measured by the distance 
between the oriflcium vaginse and the orificium uteri. I say, in 
strictness, yet I wish you to understand, that the amount of pain, 
distress, or inconvenience, is by no means proportioned to such a 
measurement ; because you shall find that a woman, with but a 
slight descent, shall suffer vastly more therefrom, than another 
woman, whose womb has fallen twice as low down in the pelvis. 
Indeed, there are women who always find the mouth of the womb 
to peer out at the genital fissure when they are on their feet; and 
who appear to feel no pain from it; while others are observed to 
surfer the most vexatious and even intolerable pain, from a very 
slight depression indeed. 

That excellent old author, the Sieur de la Motte, sworn Sur- 
geon and Accoucheur, at Vallognes, in Normandy, and who de- 
serves for his good sense, prudence, and skill, ever to be grate- 
fully remembered, makes two divisions of the malady, one of 
which he calls relaxation, and the other, descent of the womb. 
It is very curious to see how, by the use of a few quaint expres- 
sions, he paints the picture of the case. 

"L'on appelle relaxation de la matrice lorsque l'orifice inte- 
rieur de ce viscere descend a Pentree du vagin, et quelquefois 
jusques entre les grandes levres, qui se fait remarquer en y 
touchant avec le doigt, par un corps d'une consistance moyenne, 
entre le dur et le mou, qui retrograde a mesure qu'il le pousse, 
et qui revient aussitot qu'on a ote son doigt, et qui se retire ou 
reprend sa place d'elle meme lorsque la femme se couche snr le 
dos, et qu'elle a dans sa situation les reins un peu plus bas que 
le siege." 

The descente is where the os uteri comes quite out of the sinus 
pudoris. You see that La Motte, by the few words above quoted, 
has given a perfectly graphic picture of the phenomena of oar 
case. 

Among the inconveniences connected with falling of the womb, 
are those depending on the disturbance of the utero-vesical and 
the vesico-vaginal septum, for the womb and vagina cannot settle 



PROLAPSUS UTERI. 129 

downwards in the pelvis, without dragging down with them the 
posterior part of the bladder of urine; which being fretted and 
vexed with this pulling force, is frequently prompted to contract 
on its contents— and thus is set up a course of urinary tenesmus. 
But a urinary tenesmus is itself a disturbing force. Tenesmus 
relates to a pelvic sensation ; and when your patient has a con- 
tinual prompting to make water, she has also a continual forcing 
or bearing-down feeling, which compromits the repose and com- 
fortable sensations of all the other pelvic contents. There is a 
sense of weight, ponderosity, or pressure, at the perineal strait, 
which excites pain in the hypogastric and sacral plexuses and 
their branches ; so that the poor patient not only has sensation 
where there ought to be no sensation, but it is absolute distress 
and pain. As the nerves of the womb, and vagina, and bladder, 
have a very extensive fibre connection with the whole of the 
splanchnic plexuses, and with the great sympathetic and the spinal 
nerves, — you may readily suppose that a displaced womb, like an 
aching tooth, may disturb the renal, the hypogastric and sacral 
plexuses, just as the tooth starts into existence the most frightful 
trifacial neuralgia ; and you will find on examination and reflection, 
that hundreds of poor creatures are bled and cupped, hydrargy- 
rised and blistered, and antimoniated, under a false accusation of 
hepatitis or nephritis, or spinal irritation, who really have com- 
mitted the small and venial fault only of letting their uterus fall 
downwards a meagre half inch perhaps. I hereby warn you 
against false diagnosis, for diagnosis is in practice like Captain 
Greatheart in Bunyan, encountering and overthrowing all ob- 
stacles, so that even Apollyon, who in words less polite was the 
devil himself, could by no means oppose a bar to his habit in his 
practice of succeeding always. 

You have all learned what is meant by Professor Cams' curve ; 
well — the womb, when in its proper position, coincides as to its 
long axis with the superior part of this curve ; and if from any 
degree of prolapsion it settles downwards, it follows the curved 
line of the great Saxon teacher in its fall. When at the top of 
that curve, the woman being in a standing position, the long axis 
of the womb is directed upwards and forwards, and downwards 
and backwards. Suppose the womb to fall halfway down to the 
os magnum, then it would be vertical in the pelvis of a woman 
9 



130 PROLAPSUS UTERI, 

standing upon her feet : — if it were to lapse downwards, so as to 
show its lips jutting through the os magnum, the womb would 
necessarily lie in a position nearly horizontal ; its mouth looking 
forwards under the crown of the pubal arch, and its fundus point- 
ing backwards towards the lower third of the sacrum. 

Imagine your patient situated as I have just described ; and I 
think you may readily understand why she has both vesical and 
rectal tenesmus ; pains in the sacral and lumbar regions ; pains 
in the groins from discomfort and traction as to the ligamenta 
rotunda; some uneasiness in the ligamenta lata; while the recto- 
vaginal septum is strained, and the fundus of the womb actually 
rests and is pressed upon the inferior parts of the rectum, irri- 
tating it like a mass of scybala lodged in it. 

Nerves from the lower end of the spinal cord are distributed on 
the womb and vagina, and to the bladder and rectum, as you may 
perceive in good Professor Tiedemann's beautiful drawings of the 
uterine nerves, and in Robert Lee's Treatise on Midwifery, but 
they receive a considerable endowment of nerve filaments detached 
from the great sympathetic. They also, in the same manner, are 
allied to the renal plexuses, the solar plexus, and, in fact, to the 
whole organic innervative apparatus. What a great disturbing 
power does this impart to the reproductive organs when sick ! 
what an uncomfortable creature is a woman with a prolapsion ! 
have we any cause of surprise or wonder to hear her complain of 
her hypogaster, of her groins, of her thighs, of her loins — of the 
region of the kidney or liver — or, indeed, need we feel astonished 
if the whole interior of the belly become affected with the most 
intense and insupportable neuralgia. 

I had been long accustomed to regard much of the distress expe- 
rienced by females with prolapsus, as belonging to the class of 
neuralgic disorders, and my opinion on this point has been, for 
many years, confirmed by the occurrence of singular cases, to 
which I had not seen any allusion in books, until I met with an 
account of similar cases in the recently published work of Mr. 
Maunsell, of Dublin, a work which, although small in size, is 
replete with sound doctrine, and rich in numerous and important 
practical details. I have now met with about thirty instances ; 
in which, the most cruel neuralgia of the whole belly, with sen- 
sibility equal to that of acute peritonitis, proceeded solely from a 
very slight degree of uterine prolapsion. I say so, for when I 



PROLAPSUS UTERI WITH ABDOMINAL NEURALGIA. 131 

could not press the palps of my fingers ever so lightly on the ab- 
domen without giving great pain, I have found that, when I sup- 
ported the womb on. my index finger, pushing it upwards less 
than half an inch, the woman could not only allow me to touch 
the abdomen, but even to touch and press it very violently with- 
out complaining. From all this I conclude that much of the 
pain of prolapsus uteri depends on the pulling or stretching of 
nerve fibrils, caused by the sinking downwards of the organ. 
The patient feels instantly well, if you push the womb up to its 
place, or, I should rather say, if you elongate and carry out to its 
usual dimensions the tube of the vagina: when the vagina is up, 
the womb cannot be down. These cases I have been, for seve- 
ral years past, in the habit of relating in my lectures, as will 
be easily recollected by any of my early pupils who may peruse 
this page. I have also spoken upon this subject before a numer- 
ous assemblage at the Philadelphia Medical Society, in the winter 
of 1833 and 1834. The cases to which I allude may be exem- 
plified by the ensuing statement. 

On the fifth day of July, 1828, I was called to see 

, a mulatto woman, in Water street, aged about thirty 



years. She was lying upon her back; the knees were drawn up, 
and she was supporting the bed-clothes with her hands, lest they 
should press upon the abdomen, which was so exquisitely tender 
and sore, that she could by no means endure their weight or pres- 
sure. She had been suffering this pain for many hours, and had 
a short quick respiration, on account of the pain which any ex- 
tensive motion of her diaphragm communicated to the abdomen, 
and which made it necessary for her to restrain the respiratory 
movements as much as possible. Upon hearing her account of 
the symptoms, witnessing her distress, and observing her decubi- 
tus, I was at first convinced that she was laboring under intense 
inflammation of the peritoneal coat of the intestines. The slightest 
pressure of my hand on the abdomen was resisted with exclama- 
tions; for the part was, to the greatest degree, quick and sensitive. 
Upon examining the state of the pulse, which I expected to 
find tense and corded, I was much surprised to discover that it 
was nearly natural, as respected its frequency, volume and hard- 
ness. The incongruity of the signs derived from the examination 
of the abdomen and of the pulse, led me to make further inquiries. 
She had borne several children, of which the youngest was now 



132 PROLAPSUS WITH NEURALGIA. 

about a year old. I became convinced that her pains were those 
of prolapsus — a neuralgic state of the abdomen, produced and 
maintained by a misplaced womb. In brief, I obtained permission 
to make an examination per vaginam • and upon pushing up the 
womb, which I found very low down near the vulva, the abdo- 
minal pain suddenly ceased, and in a few minutes afterwards she 
could bear, and did bear, without shrinking, the rudest pressure 
of the hand on the abdomen. This was the second instance of 
this sort of disorder I had met with; the first one having occurred 
in a young unmarried woman, about two years before. Since that 
period I have seen more than twenty-five similar cases, all of 
which bore, with the exception of the state of the pulse, the most 
striking resemblance to acute peritonitis. I feel well assured that 
instances of disorder of the kind just pointed out, can only be 
properly denominated by the title of neuralgia with prolapsus 
uteri. 

Let me advise you not to forget what I said a little while ago, as 
to the direction and the attitude of the womb. Do not make a mistake 
in your Diagnostic; a mistake'often made in practice by respectable 
authorities, who misconceive the case as a sample of hepatitis or 
nephritis, or retroversion, whereas, it is a simple prolapsion. The 
womb descends in a see-saw manner, the fundus falling lower and 
lower towards the sacrum, while the os tincse rises towards the 
pubal arch as the fundus descends. It is not a case of retroversion, 
but a simple falling of the organ, in which it tends to become hori- 
zontal in the pelvis, instead of vertical; changing its place, how- 
ever, so as to carry its os tincse not merely nearer to the symphysis 
pubis, but even out of the pelvis entirely, below and in front of the 
arch of the symphysis. In a real retroversion, the mouth of the 
womb is not any lower, but it is rather higher than before ; in fact, 
the greatest difficulty in some cases of retroversion in the early 
stages of gestation is, that it is found impossible to get at the os 
tincse at all, so high above the pubis is it forced by the augmented 
length of the gravid retroverted organ. 

I must call your attention to a consideration, important in all 
your reasonings and administerings, as to prolapsion, and that is 
to the use of the levator-ani muscles. This great fan-shaped 
membranous muscle arises, as you know, from the outer half of 
the inner margin of the pubis ; from the obturator membrane, and 
from the ischial plane, just below the brim; and sending its fibres 



THE LEVATORS IN PROLAPSUS. 133 

downwards and inwards, goes to mingle them with some of the fibres 
of the sphincter ani muscle, and sphincter vaginae, and insert them 
generally into the parts around the lower end of the rectum and 
vagina; so that when it contracts, the effect is, to pull the lower 
end of the gut upwards, towards the plane of the superior strait. 
This muscle is granted as the chief active antagonist of the dia- 
phragm and abdominal muscles, which, in straining at stool, and 
at urine, as well as in labors, tend always to push the perineum 
more and more downwards. Now, in order to counteract this 
tendency to descent of the perineal planes, the levator is provided, 
in order to pull the perineum upwards again, and keep all things 
in situ naturali. This is an action familiar to all persons, but it 
is most strikingly perceived in the course of a labor, in which you 
shall observe that when the throes push the head of the child against 
the floor of the pelvis, and thrust it so far downwards as to drive 
it even lower than the planes of the perineal strait, making there 
the enormous perineal tumor, the whole head, immediately after the 
pain is off, by a few contractions, pulls or jerks of the levator is 
drawn back again within the pelvis, so as to make the patient ex- 
claim — "Oh! it's gone back again;" which is the fact; for of a 
truth, the head is driven down and pulled up again, in some 
labors, for several hours, by this mechanism. Now, in a case 
where this strife betwixt the tenesmic and the levator power has 
been long and fatiguing, it happens, not rarely, that the levator 
does not recover its tone and full force for months, and even for 
years after the" labor, because of the debilitation produced in it 
by its suffering in the labor: but this want of relevative power 
leaves the woman with a perineal tissue lower than it was before 
she was in labor. But, if the woman be the subject of frequent 
child-birth, her perineum grows weaker and weaker at every suc- 
cessive trial, until at last it becomes convex 'outwards, instead of 
concave, as it is in the young and the vigorous. All healthy 
young people have the anus high up in the sulcus betwixt the 
nates; but all old and weak people allow it to sink downwards ; 
until at last, in the very aged and feeble, it is not a sulcus that we 
find at the perineal strait, but a broad soft convex tumor rather. 
See, then, how important is the office of the levator-ani. See 
how it may be overstrained and enfeebled by one or by many 
labors ; and how, when it does get into such feeble health, it allows 
the pelvic viscera to sink, or prolapse. Do you not, also, in this 



134 THE LEVATORS IN PROLAPSUS. 

view of the case, perceive how it may happen that habitual cos- 
tiveness of the rectum may weaken the levators, and depress not 
them only, but the whole perineum, and all the contents of the 
pelvis, which in a degree repose upon it, and depend upon it for 
their best support? It appears to me that a true prolapsus uteri 
can hardly take place while the levators are strong, and, that we 
cannot have a weakened and enervated levator in the female, 
without more or less of prolapsus, or tendency thereto. 

Where the levators have thus become injured, there will be the 
sense of weakness, weight and bearing down in the pelvis ; and 
this is one of the sources of those complaints that are made by the 
patient. 

This complaint of bearing-down, is, being interpreted — tenesmus 
uteri. Stephanus says, tenesmus, or more properly tenasmos, 
tswaanos id est crebra et inanis voluntas egerendi ; a vain and fre- 
quent desire to evacuate ; which is Pliny's account of it. How 
can you have such a crebra et inanis voluntas, if your levator 
be strong! I am very sure if you had any art to give to a poor 
woman, with prolapsus of the womb, a great thick red levator 
muscle, she could no more have a prolapsus, than she could have 
a procidentia while the constrictor vagina? is closed with a spas- 
modic force. 

Levret says that but few women with descent of the womb are 
ever radically cured, by any treatment whatever, and are unable 
to dispense with the use of the pessary; and quanjl elles devien- 
nent assez heureuses pour n'en avoir plus besoin hors de la 
grossesse, ce n'est que lorsque de tres maigre elles sont devenues 
tres grasses, en faissant un usage constant du pessaire. — VArt 
des Accouchemens, p. 433. 

I think Mons. Levret cannot be borne out by facts in this dis- 
couraging statement, for I have certainly met with many women 
who have recovered, and yet have not grown fat. A lady long 
subject to prolapsus, who used a pessary for four years, told me to- 
day, May 13, that she is perfectly well : she is no fatter than she 
was before. 

Let us now consider the foregoing observations, in order to 
ascertain what results we have come to. 

1. The womb rests at the top of the vagina, a membranous 
tube, attached partly, on its posterior face, to the rectum ; on its 
sides, to the cellular tela included between the laminse of the liga- 



DIFFICULTIES OF DIAGNOSIS. 135 

menta lata ; and in front, to the bladder, to which a part of the 
womb also adheres. 

2. The natural position of the womb is one in which its long 
diameter coincides with the upper extremities of Prof. Cams' 
curve. 

3. In descending, in prolapsion, it slides down Cams' curve, 
so that, at last, it becomes horizontal in the pelvis, from which, 
4. in procidentia, it finally escapes. 

5. As long as the vagina retains its dimensions, there can be 
no prolapsion. 

6. In all prolapsions, when the vagina recovers its pristine 
longitude, the prolapsion ceases, and so in proportion. 

7. There is always some complicity of a feebleness of the leva- 
tors, with a prolapsion of the womb. 

8. Prolapsus uteri is not a disease of the womb, but only a dis- 
ease of the vagina. 

9. The indication of cure in prolapsus is an indication to cure 
the vagina. 

In this, as in most of the sexual maladies, the difficulty of effect- 
ing a cure is greatly enhanced by those sentiments of a fastidious 
delicacy which sever so trenchantly the two sexes from each other 
in the ordinary relations of social intercourse ; and to such a de- 
gree does this extend in this class of maladies, that the patient 
ordinarily conceals the fact, or the extent of her suffering, lest, 
upon betraying them, she should be compelled to make confession 
to the physician; so that our duty in the cure is greatly embar- 
rassed by the advanced stages at which the malady has arrived 
before it is placed under our care. 

We are, in many instances, not permitted to institute the only in- 
quiries that would possibly reveal to us the precise nature and 
indication of the case. Even after we have been consulted, and 
where certain concessions are made, there often remains some 
degree of uncertainty, because we cannot, as we can in persons 
of our own sex, freely employ every means of research in ex- 
ploring, and in repeating the explorations of their maladies. 

This difficulty is probably greater in this country than it is in 
Europe. I am rejoiced at it; because, however inconvenient, and 
however baffling in the particular instances of suffering, it is an 
evidence of a high and worthy grade of moral feeling. And I 
hope the day is far distant when the spectacle shall be seen in our 



136 DIFFICULTIES OF DIAGNOSIS. 

hospitals, of troops of women, waiting, in succession, for a public 
examination of their genitalia, in presence of large classes of me- 
dical practitioners and students of medicine. I regard this public 
sentiment, as to the sanctity of the female modesty and chastity, 
as one of the strong safeguards of our spontaneous public polity; 
— for woman, and man's respect and love for her, are truly at the 
basis, and are the very corner-stone of civilization and order. 

He is but the pander of vice who parades his thousands of ute- 
rine cases before the public gaze ; and is himself an unchaste 
man, who ruthlessly insists upon a vaginal taxis in all the cases 
of women's diseases that, however remotely, may seem to have 
any, the least connexion with disorders of their reproductive 
tissues. 

While I say these things to you, my young friends, I am bound 
also to say, that it will be your painful, even your distressing duty, 
to condescend to the task of making such explorations sometimes. 
It will be your duty either to do so, or to desist from taking the 
responsibility of curing the patient, whose case you can by no 
other proceeding become acquainted with. Yet even in this offi- 
cial ministry it is possible so to demean yourself, to be so filled 
with respect and with compassion for the afflicted, as to discharge 
the obligation without wounding the self-esteem of the patient, or 
lowering yourself from the high station of a missionary of health, 
furnished, by the blessing of Providence, with the wisdom and the 
skill, not truly to raise the dead, and give sight to the blind, but 
yet to make truly alive again, driving away the dark-winged 
fiend who is hovering over his promised victim, and scattering 
roses where the lily only drooped before, and opening up in re- 
newed freshness and copiousness, the fountains and streams of 
life, and hope, and enjoyment that always gush at Hygeia's feet. 

What need have I to speak further in this letter as to the signs 
by which the case of prolapsus uteri may be discriminated from 
all other affections? If you remember the manner in which Prof. 
Cams' curve is projected, you will also at once perceive what 
must be the attitude and direction of the womb in all the succes- 
sive stages of its descent to the bottom of the pelvis. But lest 
you should have forgotten that famous projection, let me describe 
it again. Bisect a dried pelvis from front to rear; set one leg of 
a compass on the symphysis pubis; open the compass two or two 
and a quarter inches, equal to the semi-diameter of the superior 



137 

strait measured from pubis to sacrum ; then describe with the 
free leg an arc of a circle, commencing at the plane of the upper 
strait and terminating before and below the crown of the pubal 
arch. This is Cams' curve, or the curved axis of the excavation. 
This is the curve coincidently with which the centre of the fcetal 
encephalon moves in passing through the pelvis, in labor; and it 
is the curve down which the womb slides as it descends in pro- 
lapsion of the uterus ; so that, when the womb is high, the os tincse 
looks downwards and backwards; when half down, it looks down- 
wards; whereas, when quite down, it points forwards. 

Please observe, however, that in the descent of the non-gravid 
uterus, there is no distension of the perineum like that which at- 
tends the advance of the foetal head. Consequently, the lower the 
w r omb sinks, the more horizontal does it become, since the peri- 
neum presses the escaping cervix uteri quite up to the crown of 
the arch. In fact, the cervix approaches the centre of Cams' 
circle as it falls, while the fundus departs from it at a tangent. 
This explanation is to help you to discriminate betwixt a true 
retroversion and a mere prolapsion of the uterus. 

There is a new book lately put forth by Dr. James Henry Ben- 
net, of London. A Practical Treatise on Inflammatory Ulcera- 
tion and Induration of the Meek of the Uterus. Lond : 8vo. pp. 
212, 1845. Dr. B. informs you that he had long opportunities 
at Paris, in hospital practice, to witness the treatment of these 
cases, and to make very careful researches as to their true nature 
and cure. The result is that, in prolapsus, there is always swell- 
ing or engorgement of the neck of the womb ; which, by its 
weight, pulls the organ down, dragging the vagina with it. Such 
is Dr. Bennet's proposition ; and I now lay it before you in order 
to ask you what you think of its reasonableness. Please observe, 
that an engorgement and swelling of the vaginal cervix uteri 
w r eighs and pulls downwards the whole organ; and when you 
cure the engorgement, then the ponderosity being done away with, 
the womb rises again to its accustomed place. I quote from page 
53. " The uterus is so slightly poised or suspended in the cavity 
of the pelvis, that the slightest modification in its volume gives 
rise to a change in its position. The inflammatory hypertrophy 
of the cervix increasing considerably the specific gravity of the 
inferior portion of the uterus, the entire organ descends, prolap- 



138 BENNETTS VIEWS. 

Now here is a rationale which you are to accept, and accept- 
ing, you are to act upon it as a guiding principle in practice ; or 
you are to regard it as unsatisfactory in itself, and incompetent to 
control your therapeutical or chirurgical ministrations. Judge 
now: the weight of a non gravid womb seldom ever exceeds 
two ounces, and of that the vaginal cervix constitutes not more 
than one-fifth part. But the author says that the engorgement 
and swelling of this fifth part drags the womb and vagina down 
to the bottom of the pelvis, and of course tends to precipitate them 
both entirely outside the cavity. Is this a reasonable rationale? 
Does it comport with other and analogous facts ? Does the womb 
tumble out of the genital fissure because it grows heavy with 
gravidity, or with heterologue development; and does not the 
weight and heft of a womb at three or four months of gestation, 
far exceed any imaginable augmentation of its weight in engorge- 
ment and swelling of the cervix uteri ? But, if a gravid womb 
of three months is not a fallen womb, why should an engorge- 
ment of the cervix, not amounting in increase of weight to one 
ounce for the whole organ, have such an effect? I cannot think 
you will accept Dr. Bennet's rationale ; nor will you twit me with 
the so oft repeated French axiom "a ventre plat enfant il y a — " 

You will meet with many cases of swollen and hardened — 
even indurated womb, in which that organ comes to weigh a 
pound or more, and yet it does not necessarily prolapse. I cer- 
tainly have had many such under my care, — and have not found 
them to prolapse — indeed, I am sure that one of the worst proci- 
dentias I ever saw, was that of a womb which would not, in the 
scale, weigh more than an ounce ; how, then, can I believe that 
prolapsus is the effect of increased weight of the cervix uteri 
only ? 

Dr. Bennet's explanation, then, does not explain the cause of 
prolapsus. Yet Dr. B.'s work is very well worthy of your regard; 
for it contains many cases of uterine disorders that were prudently, 
sagaciously, and successfully treated. I should be very glad if 
you would all read his work, because he is a man of sense and 
conduct, who is well esteemed in London. Nevertheless, I can- 
not agree with him in his views of the cause of prolapsus uteri. 

I should think that of a given number of cases, ninety per cent, 
will be observed in persons who have had children. Nay, I doubt 
whether ninety-five per cent, of the cases are not caused by ges- 



CAUSES OF PROLAPSUS. 139 

tation and labor; for of the cases supposed to be prolapsus, a 
very large number are not really of that class, but consist of dis- 
orders arising from faulty innervation of various tissues within the 
pelvis, and curable by other means than those that are indispen- 
sable for the successful treatment of prolapsus of the organ. 

In the early months of pregnancy, the womb, whose fundus 
grows broad and expansive, is pressed downwards into the pelvis 
by the superincumbent weight of the bowels, and by the tenesmic 
force of the abdominal muscles. So that, the os uteri settles at a 
lower plane of the excavation, yet cannot be said to be prolapsed, 
but only pressed downwards, or weighed downwards ; for there 
is no real disease of the vagina. As pregnancy advances, and 
the uterus expands with the growing ovum, the excavation of the 
pelvis becomes too small to contain it, and it accordingly, at about 
four and a half months of gestation, rises above the plane of the 
superior strait. "When it has thus gone up, at the period of quick- 
ening, the vagina is greatly elongated, so much so, indeed, that in 
making the examination by the taxis, the extremity of the indi- 
cator finger can, sometimes, scarcely be carried so high up as to 
touch the os tincse. 

In most women pregnant beyond the fourth month, then, you 
will expect to find the very contrary of the state of prolapsion, 
and be embarrassed in making the taxis. This is not always the 
case. For example, a woman shall have a very large and capacious 
upper strait; a strait of such dimensions as to offer no impediment 
to the escape of the head in labor. Of course, such a strait will 
not prevent the lower segment of the gravid womb from settling 
down on the very floor of the pelvis — a true prolapsus, which is 
a most disquieting thing for the woman, who is subject to a con- 
stant kneading, or tenesmic sensation, produced by the weight and 
pressure of the gravid uterus on the rectum, and its jamming 
effect on the bladder, which is thrust by it against the pubis, or 
the lower extremity of the linea alba. 

You may well venture to anticipate for such a woman, the suf- 
ferings arising from a precipitation of the womb, after the termi- 
nation of her pregnancy — for the long habitual descent of the 
vagina thus brought about, establishes in that very vagina, a dis- 
position to remain in the same curtal state long after the cause is 
removed by the birth of the child. 



140 CAUSES OF PROLAPSUS. 

These remarks show you how proper it is to enumerate among 
the causes of prolapsion, an excessive amplitude of the pelvis. 

Many women complain to us of having brought on a falling of 
the womb by some great and sudden effort that they have made ; 
such as lifting a heavy child, or raising some great weight, which 
caused the sensation of something giving way in the interior of 
the body. Many such explanations have been given to me of the 
causes of the prolapsus that my patient complained of. Others, 
again, have accused their monthly nurse of ruining their health 
by allowing them to sit up too early ; as on the fifth day, or the 
fourth day. But while it is true that a woman getting out of bed 
for half an hour at that period of the lying-in, certainly does allow 
the womb to settle downwards from its own weight, it is equally 
true, that if it remains down, after she has gone to her couch again, 
it does so on account of a weakness of the vaginal walls, which 
weakness would allow it to go quite as far down at the first alvine 
dejection, or effort to pass the urine. When I remember how the 
womb is secured in the pelvis, I cannot believe that a sudden 
effort can make it suddenly prolapse, and stay so. For, I am 
very sure that the alvine dejection of a female who is slightly con- 
stipated, can never take place but at the expense of a tenesmic 
force sufficient to push the womb lower down than it does fall in 
eight out of ten of the real prolapsions. Hence when a patient 
tells me that she made her womb fall by straining herself sud- 
denly, or by getting out of bed for half an hour, I do not believe 
her, for I cannot understand how she could produce such an effect. 
I always am ready under such circumstances to suspect that she 
may have brought about a retroversion of the womb, but not a 
prolapsion. A retroversion may take place in an instant ; a pro- 
lapsion requires a long course of preparation, before it can be ac- 
complished. 

But how is a man to know that the womb is prolapsed, taking 
his information solely from the statements of the patient ? He can- 
not discriminate between the many causes of the very same painful 
sensation; that painful sensation being the expression of distress 
arising from a great variety of states of the parts in the pelvis. 
The only way to ascertain very clearly what is the fault, is to 
examine by the touch ; and even that is insufficient in a great 
many of the cases of complaint. I say insufficient, not to detect 
a prolapsion, but to disclose the whole nature of the malady. 



PESSARIES. 141 

There is but one course to take when the patient declines to 
have her serious case inquired into ; and that is to argue the point 
with her so as to convince her judgment, and obtain her consent; 
or to decline assuming the responsibility of curing her altogether. 
It is surely better to have nothing to do with the conduct of a 
case of disease, in which the absolutely needful information is 
withheld. A physician who acts without knowing why, is more 
mischievous often than a disease left to its own native tendencies. 
Now — to continue in the care of a case you cannot cure, because 
you do not understand it, is no profit, or honor. The greatest 
profit being always attendant on him who makes the best and 
promptest cures ; and the greatest honor too. 

Dr. Heberden, in his Commentaries, chap, cii., says, " A pro- 
lapsus of the vagina or the womb, is only to be relieved by a pes- 
sary." 

The pessary is older than the time of Hippocrates. The Trea- 
tise on Diseases of Women by the sage of Cos is full of directions 
for the confection and use of a great many kinds of pessaries ; and 
some of them are still in use in the world. The pessaries of old 
were scarce looked on in a true light — for the pessa were medi- 
cated, and were applied for the most part not merely as chirurgi- 
cal but as medical, or rather as therapeutical agents. 

It is true that many of those applications were futile, and even 
ridiculous. Yet among them are to be found remedies that were 
possessed of excellent virtues. Those old-time people who knew 
nothing of the circulation or absorption — who had no clear notions 
of the nervous system, and a scant histological information, could 
not possibly enjoy the same power of discrimination as to patho- 
logical conditions or therapeutical power, as the mere tyro of 
modern days. Nevertheless, they conducted many cases with pru- 
dence and success, not because they were possessed of vast eru- 
dition and skill, but because mankind had already acquired much 
practical knowledge of treatment; and those doctors knew and 
used that general or domestic medication. I shall not copy a list 
of the curious applications in the way of pessaries mentioned by 
the Father of Medicine ; nor the strange methods recommended br- 
other ancient authors. I shall merely say that one old writer, 
Avenzoar, advises, that in an obstinate case of prolapsion, the 
woman should be laid down on the bed upon her back, and firmly 
held there by several persons sitting upon her, while a frog, li- 



142 AVENZOAR.— GYNJECIORUM. 

zard, mouse, or some other such terrific creature should be thrown 
on her feet and legs, with which she shall be so frightened, and 
make such efforts to withdraw her feet out of the danger, that the 
womb will at the same time be drawn up in its place. But I will 
give you the passage out of the venerable Arabian, so 'that the 
good son of Islam may, though he be dead, yet speak in this dis- 
tant land, whose existence he wot not of, when he was alive. 

"If the malady," says Avenzoar, "will yield to light treat- 
ment, it is well, si non, fac earn supinam jacere, et fac quod ali- 
quis sedeat super pectus suam, et alius super crura ; et fac earn 
terrere ponendo circa pedes ejus aliqua reptilia, sicut sunt mures 
vellacertae aut ranse, vel his-similia; ex quibus multum terrefiat, et 
velit fugere ab ipsis, trahendo pedes et crura ad se; et inde omnia 
membra, et corpus totum simul contrahantur ; et hac de causa 
matrix intus redibat ad locum suum ; et cum redierit matrix, fac 
elevare coxas ejus in altum, et ordina ut jaceat supinam, et prae- 
cipe ut non se moveat omnino aliqua de causa, etiam, si vellet 
assellare." — Avenzoar, Fol. 85. 

I have, besides old Avenzoar, a vast deal of learning as to 
female complaints now lying before me, in a folio volume whose 
title, printed in alternate red and black lines, is as follows : 

Gyn^ciorum, sive de Mulierum, turn Communibus turn Gra- 
vidarum, Parientium et Puerperarum Affectibus et Morbis; 
Libri Grcecorum, Arabum, et Latinorum, Veterum et Recentium, 
Quotquot extant, &c. &c. Opera and studio Israelis Spachii, 
Med. Doc. et Profess. Argentinensis, 1597. Argentina^. 
(Strasburg,) Folio. 

This celebrated work is very difficult to find ; I know of only 
two copies in this country; one of which is in the Loganian Library, 
and the other, an edition in three vols, quarto, in the library of 
Dr. J. Redman Coxe. I was unable to find it in London, Paris, 
Heidelberg, or Geneva, — and have in vain asked for it from Leip- 
sic. It was a great merit in Professor Spach to collect and pub- 
lish, in one volume, so many authors on the diseases of women ; 
and though the progress of knowledge in these latter days has 
rendered his labors little useful in the daily ministrations of our 
modern vocation, we ought all to thank him for his care in trans- 
mitting in so tangible a shape, the notions, whether sound or crude, 
of the fathers in our art. Dr. Spach's book contains the works of 
Felix Plater, of Moschion, emended by Gessner; of Cleopatra, Mos- 



GYN^CIORUM.— PESSARIES. 143 

chion, Priscian, and an anonymous author; of Trotula, or rather of 
Eros; of Nicholas Roche; Louis Bonacioli, of Ferrara; Jacob Sil- 
vius ; John Ruff; Jerome Mercuriali ; J. Baptist Montana ; Victor 
Trincavelli; Albert Bottoni ; John le Bon; Ambrose Pare; James 
Guillemeau ; Albucasis; Francis Rousset; Cordasus' account of 
a lithopsedion, or stone child ; Caspar Bauhin; Maurice Cordaeus' 
Commentary on Hippocrates' Treatise on Female Diseases ; Mar- 
tin Akakia's work on Diseases of Females, and Louis Mercati's 
four works, called Gynseciorum. 

The first work is that of Felix Plater, of Basle; then follows a 
Greek copy of Moschion, peri gunaikeone Pathone ; after which, we 
have a "Harmony of Female Diseases" Harmonise Gynseciorum; 
the third chapter of which treats of conception. I mention this, 
not to fatigue you but because I wish you to be aware that pessa- 
ries are very ancient remedies ; and that when weak people and 
quacks shall pretend to scorn them, you may not be disquieted 
on that account, and make yourself ridiculous also by scoffing at a 
necessary evil ; for you will find some, even among the Doctors, 
who think that a pessary is an incarnate demon, which ought to 
be laid in the Red Sea, with all its supporters and partisans. 
Well, this third chapter has an account of pessaries, described 
in different paragraphs, and severally designed for every variety 
of ill — I shall count them for you — and I find here fourteen differ- 
ent sorts of pessaries ; some to make a woman conceive, and some 
to make her not conceive, &c. 

As to pessaries, you would be very much amused to see the 
mixture of good sense and nonsense contained in Hippocrates' 
book, "De Morb. Mulierum" but I am sure you will not, like the 
Divine old man, tie a lady's feet up to the tester, in order to make 
her womb go up to its place ; for you know very well, that you 
can push it up to its place with your primus, and that it will stay 
up as well for your primus as for his barbarous methodus me- 
dendi. Old Sieur de la Motte, whose paragraph I quoted at the 
beginning of this letter, tells you that the womb goes up as soon 
as you push it with the finger, and comes back again as soon as 
you take away the support. The father of all the doctors, I mean 
the Sage of Cos, knew less of the nature of prolapsions than the 
honest French knight. 

You may safely make up your minds that, if you are to have 
anything to do with the management of these cases, you will be 



144 SIMULATIVE PROLAPUS. 

obliged to condescend to the use of the pessary. A man might 
as well treat fractures without the splint, as these affections with- 
out some mechanical stay and support. Remember what Heber- 
den said. 

The result is, that pessaries are necessary evils, since I con- 
clude it is better for a woman to have a pessary, and feel comfort- 
able, than not to have one, and lie all the year lounging and 
losing her health, for want of air and exercise ; so that, Dr. 
Heberden is, though not right, yet almost right in his assertion 
above quoted. 

I say Dr. Heberden is not right, but almost right ; and 
here are my reasons for saying so. I detest the pessary, as a 
disagreeable and disgusting thing, whether to order or to wear. 
I will never employ one except where a conscientious regard to 
the sanctity of the interests committed to my care seem to render it 
indispensable. It is not always indispensable to think even of 
the pessary, because a female has pain in the back and hypogas- 
trium, and a bearing down sensation and urinary tenesmus. When 
women complain of such annoyances, we are very apt to leap at 
once to the conclusion, that she has some deviation. But, I do 
find a very considerable number of women complaining of uterine 
tenesmus, attended with the host of nervous pains and inabilities 
that follow in the train of uterine deviations and displacements, 
yet have none. There are a great many unmarried ladies who 
complain in this way; and who, in consequence of such sen- 
sations, lose their spirits, and give themselves over to a habit of 
moping and fretting, out of some prospect they set up before their 
fancy, of uselessness and worthlessness in the world. What, 
indeed, can be more discouraging and melancholy for a fine girl 
than the idea, that she lets into her brain like an idee dominante, 
as Esquirol calls it, that she is unfit to be married; that she cannot 
have children ; that she has some horrid malady of those private 
parts of her person, on whose health and perfection all her charms 
depend — because, she well knows that a woman with a uterine 
disease loses her bloom, her gayety and splendor. These are 
cases simulating the phenomenon of prolapsion — and, indeed, it 
may be that there is some slight descent of the organ, arising from 
laxity of fibres and a general debility dependent on a faulty 
hsematosis. Such cases do not at all require that the lady should 
be subjected to the grief and vexation inseparable from a medical 



SIMULATIVE PROLAPSUS. 145 

exploration by taxis. And, in fact, the experience of the physi- 
cian should enable him, with a coup d'cdl, to determine the non- 
existence of phenomena demanding so painful a concession. Do 
not compel the young girl then to submit to the abasement of a 
vaginal examination except on a well-founded opinion of its ne- 
cessity for her — and for you. When it is necessary, it is not an 
abasement. She is a fool to refuse it ; and if you be a physician 
indeed and in truth, with the heart and the missionary sense of a 
physician, God's messenger, I say she is a fool to decline your 
proffered aid. 

Remember that pelvic pain does not always imply deviation and 
displacement, — though the patient herself may imagine that it does, 
and is unhappy about it ; yea, even sick. I assure you I have 
encountered and do frequently meet with many young girls, and 
certain young married women also, who are thus afflicted with a 
thought, oppressed with a notion, and slowly assassinated by an 
idea. In encountering such a case I have often proceeded as fol- 
lows : and I beg you to pardon me, and I beg the pardon of all the 
critics, who perhaps will gibbet me to all the brethren for twenty 
years, should my name last that long, for daring to put such things 
in print. Things that they will say are below the dignity of com- 
position, and a complete innovation on the time-honored solemnity 
of the powdered wig, square-toed shoes and buckles, and gold- 
headed cane of the Medical Faculty. I say I beg pardon of the 
critics ; and hope they will overlook me, as I consider myself in 
the act of holding a plain conversation with each one of you in 
particular in my own library here at home, as I told you I should 
do, when I engaged before all the class to send you these familiar 
letters. 

I was requested on the day of 184-, to visit Miss 

Helen Blanque, at No. — Chestnut street, and when I called at 11 
o'clock in the morning, I found her reposing in a luxurious fau- 
teuil of the richest crewel work, arrayed in a beautiful negligee, 
with her slippered feet resting on a low ottoman. The apartment 
was richly furnished with mirrors, and chandeliers, and candela- 
bras, and carved sofas, with chairs of every form and hue. A fresh 
bouquet stood upon the little table near her, by half a dozen vol- 
umes, some of which were opened and lying on their faces, as if 
taken up and laid down in disgust ; her hair was in curls, but 
carelessly; and the tout ensemble of the young lady was expres- 
10 



146 SIMULATIVE PROLAPSUS. 

sive of languor and indifference, if not of pain or distress. As 
she was an old acquaintance, I could speak to her very familiarly, 
and so I began the following conversation : 

" Good morning, my dear Helen, I hope you are not very sick ; 
and indeed I must think you are not, if I may judge by your fair 
face and bright eyes. What can you possibly want with a Doctor? 
Don't you know it is a very dangerous thing to meddle with people 
who go about the world with their pockets full of lancets, blue 
pills, and iodine ?" 

" Oh dear me, doctor, I am very ill indeed ! and I desired to 
know if you could do anything that might enable me to get rid 
of the pain and weakness I have endured so long?" 

"How long?" 

" Why at least two years and a half I have been absolutely 
broken down with distress. I can't stand up nor kneel at church 
without misery ; I faint at Bailey & Kitchen's or at Levy's counter ; 
the opera kills me, — I cannot dance, much less waltz; and if I 
am to live this way, I declare my opinion is fixed that life is no 
boon." 

" Tilly vally, child ! there is little the matter with you. You 
are not half as ill as you think for, as I shall soon show you." 

" I didn't think that Dr. M. would make game of a lady's 
sufferings." 

" No, indeed ! I shall make no game, no light matter of it ; so 
don't fret, my dear; but let us have a complete understanding with 
each other. I, that I may know what duty I have in relation to 
your case ; and you, that you may learn how far you ought to be 
obedient to my counsels. To begin, then, what is your age ?" 

"I am just turned of two- and -twenty." 

" Charming age! Have you ever had violent diseases, as 
fever, inflammation, scarlatina, rheumatism?" 

" Never ; I have been very healthy up to the time of this ill- 
ness." 

" Please! what was your age when you changed?" 

"I was not quite fourteen." 

" Was you well before, during and for some time after that 
occasion?" 

"Perfectly." 

"Have you been regularly periodical ever since ?" 

"Exactly so." 



SIMULATIVE PROLAPSUS, 147 

" How many days?" 

"Five days." 

" How many changes from first to last ?" 

"Twelve." 

"Always a dozen, eh!" 

"Yes, — perhaps sometimes ten, sometimes perhaps fourteen?" 

"Is it still the case?" 

"No, sir; I have for the last year not had more than six to 
eight. I do believe it's leaving me." 

"Pshaw! Have you appetite?" 

" Capricious — yes, I can dine pretty well ; and I like my cup 
of tea; but I have no real pleasure in anything." 

"How is the sleep?" 

"The sleep? why, not good — so, so — often waked — often dis- 
turbed by dreams." 

" You must tell me something as to your digestive powers. — 
Have you acidity and flatulence ?" 

"Yes, very much. I have the bouche pdteuse every morning, 
a horrid, vile taste in the mouth and throat — " 

"And the daily evacuation — is that right, or are you a little 
constipated?" 

" Oh, very much. I am always obliged to take Seidlitz, or 
rhubarb, or some other medicinal horreur." 

"Well, that's enough now. As to exercise, pray, my dear, 
have you walked three hundred and sixty-five miles since this day 
a year ago ?" 

"Three hundred and sixty-five miles! why, doctor, what are 
you thinking of? Three hundred and sixty-five miles, indeed ! 
What an idea !" 

" But consider, if you have not walked three hundred and sixty - 
five miles in a year, you have not walked as far as from Front to 
Eleventh street once a day, and that, you know, is but just a mile. 
How can you expect to be well and keep clear of the doctors un- 
less you do at least that much walking?" 

"Why — bless your soul,, doctor! I can't walk round a square 
without suffering the most dreadful pain in my back and down my 
limbs ; and if I ever stand before the glass to put up my hair in 
the morning I feel as if I should drop ; in fact, I am now always 
obliged to sit down to dress my hair." 

"Very good, child, I see how it is with you, and how it's like 



148 SIMULATIVE PROLAPSUS. 

to be, if you take your own counsel ; and that is, that you'll get to 
be bed-ridden, and come to what the farmers call lifting. But I 
shall provide against that ; for be assured I shall compel you to 
walk six miles every day of your life, rain or shine." 

"You might as well talk of six hundred as six, sir; and, in 
fine, I see you have no idea of my state at all ; nay, the very 
reverse." 

" Perhaps so, my darling; and if so, I ought to learn more par- 
ticularly what your real condition is. Will you suffer me to knock 
on your chest a little bit ? 1 wish to percuss it a little, merely to 
learn what kind of sounds it may yield when struck upon." 

"Yes, sir, as you please." 

And so I percuss her thorax all over with the most healthful 
resonance everywhere. 

"Now put your fingers to your mouth and draw in your breath 
between them so as to make a hissing sound as the air rushes 
into the lungs. Do it slowly, and as long as you can. I wish to 
judge as to how many cubic inches of air you can inhale at each 
forced aspiration. Do it thus — so— just as I show you how. 
Yes, that's well. Why, you imbibed at least fifty cubic inches, 
with one aspiration, and that is most admirable. Your lungs are 
as sound and as light as the last new sponge from Cephalonia or 
Corfu. Now, sit still and don't speak — I am to count your breath- 
ings. There, — you breathe fifteen times a minute, and that is just 
right; just nine hundred respirations to the hour, and very suffi- 
cient full ones they are. I must count your pulse — let's see — 
seventy-two beats to the minute ! — regular in the intervals as the 
town-clock pendulum! But your face is rather pale, I see ; nay, 
you are by this better light, quite pale. Have you been so long?" 

"Oh yes, sir, these two years; these two mortal years." 

" No wonder! — nobody can have color, except out of the rouge 
saucer, who does not walk at least two thousand miles per annum 
in the open sun-light. What is your ordinary weight ?" 

"Oh, doctor, I used to be exactly witches' weight, one hundred 
and seven, you know; but now I'm all gone, and am only ninety- 
six and three-quarters! Ain't it dreadful?" 

" That is a pity! Let me feel your arm. Come, there's some- 
thing left of you yet, for your arm is not an absolute parallelo- 
piped, though it's not as round as I could wish ; and I perceive 
that your muscles and tissues are soft, not solid like wood." 



SIMULATIVE PROLAPSUS. 149 

"Yes, indeed, I am in a most dreadful state!" 
"Well, never mind your dreadful state — never mind that — wait 
a little till I cure you, and you shall, with the blessing, have two 
cheeks like the sunny side of an apple; and those pale lips 
shall pout like twin cherries. But I have one more inquiry to 
make, and that is, as to your real ability to move about. Don't you 
find when you go up stairs that your heart throbs very much ?" 

"Throbs! Doctor! why, it jumps up to the top of my throat! 
and I am so out of breath that I am obliged to stop on the stairs 
once or twice before I can get up to the top ; and my poor knees 
feel as if they would bend under me in spite of my will. In fact, 
doctor, my free-will over myself is nullified and abolished ; so 
you see if you cure me at all, you are to clear me of those two 
pests of the time, nullification and abolition." 

" Very good, very good, dear, I take. That's very well. But 
let us try an experiment : I wish to count your pulse again. 
There ; — it beats while you are sitting on the sofa, just seventy-two 
times a minute, as before, which is right. Now, go out at the door, 
and walk to the top of the stair ; not in a hurry, but in a good pace, 
as if you were going up for your hat or shawl ; and as soon as 
you come to the second story, turn and come back to take your 
seat again, that I may feel your pulse after the exercise. I want 
to know how many additional pulsations you will require to carry 
you to the top of the stair — that's the object of my experiment." 

Upon her return I found the pulse 140 per minute, (I have 
often counted it at 160 for such a trip,) and said to her, " See 
here now what an extraordinary thing. Your pulse, before you 
went out, was seventy-two — it was one hundred and forty upon 
your return; that is to say, to carry you up sixteen feet, the 
height of the ceiling, your heart was required to beat sixty-eight 
extra times, or one hundred and forty times per minute. Do you 
understand that, or is it all Greek and Hebrew to you?" 

"Indeed, indeed, I hav'n't the least notion of it except that it 
tires me to death to go up, and makes my heart palpitate like the 
fluttering of a pigeon. It's very strange." 

"No, indeed," I rejoined, "there's nothing strange in it; and I 
can make you understand it very clearly in a few minutes, if you 
are willing — and I should like very much to inform you; because, 
if you could but understand what you really require in the waj 
of a cure, I suppose it would be far easier to cure you." 



150 SIMULATIVE PROLAPSUS. 

" Oh, pray do, doctor, tell me all about it, for I'm dying to learn. 
I like reason and common sense above all things. I detest faith 
and obedience, except to the Gospel; and I am a full believer in 
common sense and conviction. If you address my common sense, 
you will command my most implicit faith and obedience. Wo- 
men, who seem to be a sort of human Parias — who have lost 
caste, — are always flattered and soothed by being treated as if 
they were really reasoning beings ; for when so treated they seem to 
have regained their caste. Tell me, then, as clearly as you can, 
without any of your Latin and Greek technicalities, what it is that 
ails me, for I assure you I am most miserable, most unhappy." 

"Well, open your ears — or rather, as Antony said to the mob, 
'lend me your ears,' not that I may pour any 'leprous distilment' 
of Latin or Greek into their porches, but that I may fill them with 
some of the most enchanting truths of Biology, or Life-doctrine, 
which is the same thing. Do you know what Moses the prophet 
said about you, my dear? and he was a prophet." 

"What did Moses say about me?" 

"Why, in speaking of you, he said ' the blood thereof is the life 
thereof which was equivalent to saying that where there is no 
blood, there is no life, or this other equivalent : where the blood 
is bad, there is a bad life, a life not strong — not healthful, hardly 
worth having as a gift! Miss Helen thinks so." 

" Oh, my! Doctor! do you mean to say my blood is impure? 
what a horrid idea ! — how very dreadful — shocking!" 

" Far from it, my dear; it's bad, because it's too pure — it's too 
delicate, too lady-like, too thin, too weak — too dilute. — It has 
not enough of consistency, which the doctors call Crasis, to effect 
fully all the purposes for which it was given to you, except when 
you are sitting or lounging merely. But for any emergency, it 
is not strong enough ; for example, it is strong enough at 
seventy-two beats of your heart to let you sit on that fauteuil 
very comfortably ; but it must have 140 beats to walk you up 
one pair of stairs — and I am sure if it would be hurried by 200 
pulsations, it is not strong enough to lift you to the top of the shot- 
tower down yonder by the Navy Yard!" 

"Ah, doctor, you are using parables with me; and I can't read 
them." 

"To be sure you can't; I didn't expect you could; but you 
will by and by. See here ; — here is a very large vein on the 



SIMULATIVE PROLAPSUS. 151 

back of my hand — I suppose you know what a vein is, don't 
you?" 

" Oh yes — that's a vein, and so is that." 

" True ; but what's a vein for?" 

"I'm sure I don't know; but I believe they are where people 
are bled, arn't they?" 

" Yes — but if people are bled from their veins, it is because 
there is blood inside of them. But attend to what I say. You 
see here — here is a vein — and you are to understand that a vein 
is a blood-tube. This one on my hand, is about the size of a 
swan quill, is it not?" 

"Yes, sir." 

"But this tube, this swan quill has another tube inside of it — 
a quill inside of the barrel of the swan quill, and the two grow 
fast to each other, making a double tube ; do you understand 
that?" 

"Perfectly. That's very clear." 

"Very well; now you see I have many veins on the back of 
my hand ; for I am getting old, and they become more visible in the 
aged, than in such young things as you: look at your own hand — 
I see a small blue trace where the delicate vein tints through the 
translucent skin. How pretty it looks ! But you see I have not 
one vein only, but a thousand — nay, perhaps many thousands — 
which are connected with certain still smaller tubes, that are 
called by us capillaries, because capillum is Latin for a hair, and 
because these capillaries are as small and fine as hairs. They 
are all blood-tubes. Do you see ?" 

"Oh yes, very plainly." 

"Well; these capillaries are millions and billions in number; 
but they are the fine extremities of arteries and beginnings of 
veins. Arteries are the tubes that beat; we feel an artery to dis- 
cover its pulses, its pulsations. When a doctor puts his finger on 
your wrist, he does it in order that he may feel your arterial pulse. 
That pulse is caused by the action of the heart, which fills and 
empties itself by turns of blood, discharging it into the arteries. 
As it forces the blood out, it forces it with a pulsatory motion. If 
the pulse is big, hard, violent, — it is because the heart sends out 
muc h — violently — into a tube that strongly resists it ; and there- 
fore the tube feels hard, big, strong. So now you are to know 
that the arteries, the capillaries, and the veins, are all alike in 

10* 



152 SIMULATIVE PROLAPSUS. 

consisting of double tubes, the end of one being the beginning of 
another ; or one interior tube contained in an outer tube or 
sheath." 

" I understand you perfectly; — pray go on. Oh, how I should 
like to be a doctor." 

" No you wouldn't ! For it is the most abominable vocation 
ever gentleman was engaged in, or woman either. But let us 
proceed. 

" Now, how much blood do you suppose is in that little 96 
pounds of a body of yours?" 

" How should I know ?" 

" Sure enough, how should you ? but it is variously estimated 
at 500 or 600 ounces — but, 500 ounces is 31 pounds; leaving you 
65 other pounds of flesh, bones, and so forth. But all this blood 
is contained in those arteries, capillaries, or veins, we were just 
now talking of. And the blood is not in contact with any part of 
your whole volume, save that inner tube, that inner quill within the 
swan quill; but, that inner tube is the ' common membrane of the 
blood-vessels,' and it would be much more sensible of us, if we 
would never call it by any other name than the blood-membrane, 
or the blood-making membrane : and if I were not too well-bred to 
speak Greek in your ears — a sort of 'leprous distilment,' I might 
call it the Hsematosic membrane, a Greek work that signifies blood- 
preparing, or blood-manufacturing membrane; or perhaps I might 
call it the Endangium, which means the inner vessel, or inner tube, 
for that is the name that is preferred for it by the great German 
physiologist, the illustrious Burdach ; and a very pretty convenient 
name it is, which expresses the idea of an inner vessel. 

" If all the blood in your body touches this membrane, this 
tissue, and nothing else, — then you have wit enough to perceive 
that, whatever be the cause of the production of the blood, that 
cause must exist in this hsematosic membrane ; I say exist in it, 
either originally resident therein, or at the least transmitted there- 
through. This membrane is the ultimate, or the penultimate tissue 
in the hematosis. 

"Suppose that membrane to be all right — all well — perfectly 
healthy and active in the performance of its duty in making 'the 
blood thereof,' don't you see that 'the life thereof will be good 
and strong, and durable and pleasant. But, suppose, on the other 
hand, that the hsematosic membrane is pale, flaccid, sick — weakly 



SIMULATIVE PROLAPSUS. 153 

— good for nothing, can't you see that * the blood thereof will be 
like 'the life thereof — good for little, or good for nothing!" 

"Oh yes — certainly, how very curious, — and how vastly 
amusing!" 

"Amusing! it's more than amusing, it's useful. 

"But come, let's get on with our lecture. See here, now, 
here's a little shagreen box, with this brass tube in it, that I 
shall take out. This is one of Dr. Donne's microscopes, — it is 
composed of certain magnifying glasses so adjusted the one be- 
hind the other, that any object seen through it, is greatly mag- 
nified ; and, indeed, you can discover in it objects so small as to 
be far too minute to be seen by the naked eye. It's a very pretty 
instrument, and a very useful one, too, especially to us; who often 
have occasion to see things, that other people cannot see, — and 
we do see them, too, though the vulgar accuse us now and then, 
of pretending to see through a grindstone; lend me a needle." 

"A needle, oh! I haven't one." 

"Not a needle! — what should a lady do without a needle? I 
thought a lady and a needle as inseparable as Chang and Eng. 
It's a bad sign, when a lady has no needle ! well, then, a pin — 
surely you have a pin! now, look! I prick my finger with the pin, 
and there is a minute tropfchen of blood, and now, I have put the 
little drop on this plate of glass ; and there, it is adjusted under 
the object glass of the microscope — now, look through it ; what 
do you see ?" 

"Good gracious! what a curious sight! — why I see a million 
of berries, or peas, or shots, or little balls; no, they are not balls; 
they look like little bits of biscuits ; or rather they are like new 
thick quarter dollars on the banker's counter." 

" You are perfectly right, dear ; they do look like little thick 
quarter dollars, or small discuses. Those objects that you are 
gazing at, are magnified by the glasses, just 300 diameters, — 
and they consist of the particles of the blood, or corpuscles of the 
blood — they used to be called globules of the blood ; at the present 
day they are called blood-discs. Don't you see — they are floating 
in a kind of watery fluid? Well, that is the serum of the blood. 
— Was you ever bled ?" 

"Dear me, yes! what American was never bled !" 

"Sure enough! Well, when you was bled, the blood divided 
itself into two parts, one red solid cake part, and the other a pale 



154 SIMULATIVE PROLAPSUS. 

yellowish fluid or watery part: you see those parts separate in the 
microscope. The discs are the red blood, and the other the serum 
or watery part. If you was bled for a pleurisy, you probably 
observed on the top of the red cake clot, a.thickish or buff- looking 
colored matter, or crust — that was another portion called fibrin. 
The last portion to be named, you never saw — it is the albuminous 
portion, or albumen (which is very nearly pure in white of eggs), 
dissolved in that watery part of the blood in which you see the 
discs floating, so that though it is there, you don't see it — neither 
could you see a lump of sugar, w T hen it is dissolved in your glass 
of eau sucree. Now come, we have analyzed the blood, and di- 
vided it into four parts, or kinds of things, 1, discs, 2, albumen, 
3, fibrin, 4, w T ater. When all these parts are justly mixed and 
proportioned, the blood is healthy, when otherwise, it is unhealthy; 
yours is unhealthy." 

" How is mine out of order, doctor ?" 

" It has too much water." 

" How do you guess at that ?" 

" I don't guess at it ; I see it and feel it." 

"You see it!" 

"Yes, truly — I see it in your pale lip and cheek; I see it in 
your hurried breathing when you walk up stairs ; I feel it in your 
pulse at one hundred and forty for rising sixteen feet upwards, 
whereas while you sit still it is only seventy-two." 

"Ah, doctor, you are in Greece, again." 

"No, my dear, not at all. It's all plain Yankee-talk." 

"It's Greek to me — nay, I fear it's gibberish." 

" Stop a bit; let me tell you that those great men, Mr. Andral, 
Mr. Gavarret, Mr. Franz Simon and many others, have analyzed 
the blood over and over again, in all sorts of diseases, as well as 
in the healthy state ; and they pretty nearly agree in this conclu- 
sion — that in one thousand grains of healthy blood of man, there 
are of 

Water 790 grains 

Discs 127 " 

Albumen 80 " 

Fibrin 3 " 



1000 grains. 
This is either the truth, or so near it, that it is safely to be 



SIMULATIVE PROLAPSUS. 155 

received as truth. But, if Moses is true, also, where he says, 
' the blood thereof is the life thereof,' then when in your blood 
the figures for the. analysis stand thus, 

Water 840 grains, 

Discs 71 " 

Albumen 80 " 

Fibrin 9 " 



1000 grains — 
it must be clear that, in as far as the blood thereof is the life 
thereof, the life is weakened, for the blood is weakened, and that's 
the fact as to you, my darling Helen. 

" Such things are scarce fit for ears polite — but for the sake 
of the illustration, permit me to say, that there was a famous 
English pugilist, or prize-fighter, named Thomas Crib. He 
was as bold as a lion, or perhaps as General Taylor. For the 
sake of an agreeable pass-time, his friends and he, too, laid 
large bets that he could, on a day fixed, beat an immense 
negro, called Molyneaux, in a pugilistic encounter; and so Tom 
was handed over to the celebrated Col. Barclay, of Uri, in Scot- 
land, for training for the fight. When he came under the colo- 
nel's guidance he was a great fatty sort of a fellow, who could 
not run a hundred yards without getting out of breath. He had 
drunk, I suppose, much beer and brandy, and lived rather a 
heedless sort of life, so that his blood was out of order and his 
flesh not so hard and solid as the Prince of Denmark's — which, if 
you remember, would not melt, though his highness was so anxious 
for it. Tom Crib's would "melt, resolve, and thaw T into a dew ;" 
and if it would, he was not fit to encounter the gigantic black 
man. Well, Col. Barclay gave him some doses of medicine, 
made him perspire, regulated his diet by weight and measure, 
made him walk, pitch the bar, run, and so forth, according to a 
prescribed rule of training, and the end was, that in about ninety 
days Tom could run a mile up a Highland hill and stand upon 
the top without drawing a long breath. In short, he was so 
thoroughly trained, that is to say, brought into such a condition 
of health and strength, that, with the greatest unconcern, he en- 
countered and easily overthrew his black-amoor adversary. Pierce 
Egan's account of it is very curious. 

" The moral of this history is a very good moral indeed — it is that 



156 SIMULATIVE PROLAPSUS. 

you do not want a Doctor, and that you do want a Trainer ; and if 
you had one, it would not be long before you could go up stairs 
beginning at seventy-two and ending at seventy-three or seventy- 
five pulses instead of one hundred and forty." 

"Well, doctor, can't you put me in a way of this training?" 

"Yes, I can ; but I can't do it like Col. Barclay. I only wish 
that instead of having a Smithsonian Institution to buy old musty 
volumes with, we had a real Barclay College to save the health 
and lives of half the nice young ladies in the land. Talking of 
musty old books, what old book is this on the pier table?" 

"Oh, I believe it is some horrid Latin thing that papa picked 
up at auction last night; and, would you believe it, he thinks he 
has got quite a treasure in it." 

"So indeed he has. Why, its a Fifteener! a copy of Seneca, 
printed at Venice by Bernadine de Coris of Cremona, in 1492. 
Bless me, a real beautiful Fifteener ! Why, that prince of bi- 
bliomanes, the Rev. Dr. Thomas Frognall Dibdin himself, or 
even the Most Noble, the Earl of Althorpe, would feel lucky to 
get' such a precious bibliographical morceau ; and what admira- 
ble preservation. Look, child! this ink is as black, and as delight- 
fully clean put on, as if Lea and Blanchard themselves had printed 
it with the Exploring Expedition press. 

" See here, Miss Helen, here is Seneca's fifteenth letter of the 
second book to Lucilius, and I find it has a passage about you. 
But you will read it yourself, won't you?" 

"What! I read such an old pagan as that, and in those horrid 
types, and that incomprehensible lingo, which, thank Heaven, I 
do not understand, nor don't wish to — nor Dutch neither." 

"Well, then, Seneca, for I must tell you of it, is speaking in 
this letter to Lucilius about the necessity of health as a means of 
happiness and activity of the mind, as well as of accuracy in its 
operations. Seneca thinks, that to be wise is to be well ; for if, 
says he, we be not wise, the mind is sick, no matter what may 
be the amount of the bodily strength; for such strength is like 
that of a raving madman, governed by no fixed principle. Hence 
he says our chiefest design ought to be to keep the mind in health ; 
and the next object should be to keep the body in health, &c. 
Next Seneca goes on to say, that it is very foolish and ridiculous 
to act, as many persons of his time were used to do, — namely, 
pass their whole time in exercises calculated to strengthen the 



SIMULATIVE PROLAPSUS. 157 

arms, and neck and sides ; because, the very best school of gym- 
nastics will never be able to make a man either as strong or as 
heavy as an ox." 

"Why, doctor, what has all that to do with me?" 
"It has this to do with you, child! it serves to show, that in 
Seneca's time, people did devote some portion of the day to the 
conservation of the health. And the good old man finds fault with 
them for carrying their care over it too far. I am very sure myself, 
that the Romans and the Greeks before them, were much wiser 
than the English, the French, the Germans, or the Anglo-Ameri- 
cans, in respect to their care over their persons. They did devote 
much time, many of them, as Seneca says, too much, to the study 
and practice of those exercises, baths, dresses, modes of diet, &c, 
that kept them like Tom Crib, in constant training. And, in fact, 
the consequence was, that the Greek Phalanx was irresistible and 
irreversible ; and a Roman Legion thought no more of a cloud of 
Persian cavalry, or Dacian spear-men, than Rough and Ready did 
of the Peons of Mexico. The gymnastic usages and habits of the 
Romans, enabled them by strength and activity to conquer the 
world ; indeed, they were a set of complete Tom Cribs. To be 
sure, they got much glory and a great deal of money and lands to 
locate in as we say; but there's the other fact along side of it, 
that there's not a valley nor a hill, nor a river or marsh, from the 
Tanais to Gibraltar, from London to the falls of the Nile, that has 
not drunk their blood, and seen their skulls grinning at the cold 
moon, and their bones mouldering under the night dew. It makes 
me melancholy to think about those fine young farmer fellows, 
like Tityrus and Meliboeus, dying for empty honor so far from 
home, leaving their Galateas and Lalages to weep in hopeless, 
hapless maidenhood, or wait for some other lover — for I am dis- 
posed to ask with old Jack in the play, can honor set a leg? No; 
or heal the grief of a wound? No." 
"How you do talk, doctor!" 

"Well, my dear, I hope it's not disagreeable to you?" 
"Oh no, far from it. Yet I confess myself blind as to any con- 
cern I have with Tityrus or Meliboeus, or Lalage and Galatea; 
what pretty names, though!" 

"You have this concern, namely; that you live in the nine- 
teenth century, and they, before the year one — and yet you don't 
know half so well how to take care of your bodily health, as those 



158 SIMULATIVE PROLAPSUS. 

old-time people did ; for the world in some respects of useful 
knowledge has lost ground, not gained it. It makes rail- roads 
to break people's arms and legs with, and steam-boats to blow them 
up ; but society is not half so elegant and grand as it was in their 
great day. Now you who are listening to my voice, cannot run fifty 
yards upon a level without panting for breath, and beating your 
little heart like a pigeon's flutter; but Galatea could run or even 
fly; does not Virgil say of her, fugit ad salices ? Nay, you can't go 
up stairs without making your pulse simulate that of a person in a 
scarlet fever. And it's your own fault, for you have not walked 
365 miles in the entire year 1846. Why, bless your soul! a bee 
thinks nothing of going to farmer Robinson's buckwheat field, six 
miles off, and back again, half a dozen times a day for a little 
honey and wax. And Sukey, the cow, would starve to death in the 
richest grass lot w T ere she to lie down or even stand still all day. 
Sukey must walk about to pick up the material for her cud. You 
lounge on the sofa, and your maid brings it to you on a silver sal- 
ver! Everything must move. I verily believe, that the mute cab- 
bages w T ould die, if it were not for the exercise that the wind gives 
them; and surely, dear Helen, if there be a real pleasure in this 
world, it must be that of a corn-field, when the zephyrs dance 
down the wheat ears, and they courtesy and wave them along, 
bowing their heads upon their slender and graceful stems as they 
pass. Don't you think the bread is sweeter and whiter for every 
motion that the winds have communicated to the dancing grain? 
There's the poor potato ! see how sick it has got ! and all from being 
shut up, like Miss Helen, in one small hole for so many years. Are 
not our houses our holes, to which we retire like the foxes in the 
Old Testament? You say you cannot walk, you cannot enjoy the 
church services to edification, because it hurts your back and 
sides, and limbs, and you are ready to drop. I was going to say, 
but shall not, hang your back ! forget your back, and your back 
will forget you. At all events, this I can most solemnly assure 
you of. 1st. That you are not ill; that you have a thin watery 
blood. 2d. That your membrana vasorum commune, which is 
your blood-membrane, your hsematosic tissue, is feeble. 3d. That 
your pains are what we call nerve pain, neuralgia, not pains from 
inflammation; and that they carry in them no element of death 
and ruin, &c. 4th. That when your blood shall stand at the figures 
3, 80, 137, 790, your weakness will be gone; your nerve streams 



SIMULATIVE PROLAPSUS. 159 

will flow from the brain and spine-cord steadily, or at the com- 
mand of your Free will ; and that the apple shall bloom on your 
cheek, and the cherry pout on your lip, and the waltz and the 
cachuca not fatigue you, and all the ghastly clouds of blue imps 
that love to hover over and about you, will be dissipated by the 
radiance of a face beaming with health and hope, and happiness, 
as Tom Moore says, 'just as the sun licks up each sneaking star. 5 
Don't you know what happens to the celery, my dear?" 
"Why, what?" 

" This happens to it ; it grows up a great green rank stock, 
hard enough to make a whip handle; very disagreeably tough and 
fibrous to the taste ; nobody likes it. It is too strong, too healthy, 
for it has been waved in the wind for its exercise, and shone on 
by the sun, which gave it color and strength. Now the gardener 
comes, and seeing the great brute of a celery stalk — he says, 'so 
Mr. Clodhopper, thou coarse fellow thou ! — dost think thou art fit 
to be admitted to an aristocratic gourmand's salad-dish? Shade 
of Brillat! — no, sir — I shall soon make a veal of you. I shall 
weaken you, sir, and take that horrid green cheek out of you, sir, 

and make you so delicate, sir, that even Miss Helen can 

digest, and approve you, sir' — and so Mr. Gardener makes a deep 
trench, and piles the earth up about him almost to the top of his 
stalk, and effectually quiets all motion in him ; in fact, he splints 
him, as we say: and what's more, the sun's life-giving beams no 
longer reach his buried stem. He grows weak, pale, watery, 
tender, — and when he is blanched like you, he digs him up for 
your salad; and the whiter and weaker and tenderer he is, so 
much more does he ask for him, and so much more do you value 
him. A stock of blanched celery may be compared to Miss Helen. 
It has not walked its mile a day, and it has been shut up in its 
room devoid of the fresh breath of Heaven, and cut off from the 
life-giving beam of the glorious god of day. You are etiolated, 
dear patient; look in the pier-glass, and see your cheek! You are 
etiolated, and that is the reason you have pain. Your pain is from 
weakness, and nothing else." 

" Can't you give me some medicine to cure my pain though, 
doctor?" 

"Oh yes, certainly; nothing so easy; take laudanum." 

"I hate laudanum." 



160 SIMULATIVE PROLAPSUS. 

"I'm glad of it. So do I. But laudanum will put a stop to 
the pain." 

" Yes; but I fear it won't cure me." 

"Certainly not. On the contrary, it will be sure to make you 
worse ; so will almost all other kinds of physic. But if you will 
have physic to cure the pain, take that pernicious laudanum, and 
then you will be like a spendthrift who has not come to his estate, 
but wants money ; so he pays the usurer two and a half per cent. 
a month, and when his grandmother dies, and leaves him all her 
property, it must be paid over to the shaver; for it comes exactly 
to the principal and interest of his borrowings. This is just a 
fair specification of what you will come to, if you will take opium 
to cure your painful sensations. But come, dear, I shall now 
be serious, and give you a prescription. Let's see; yes! Take — 

" Take courage, and be well. Then believe what an experienced 
man says, who can have no interest to deceive you ; believe that 
he knows what he says, when he tells you that a trained health is 
the health you should seek for. 

" Don't regard the pain; take the more courage, the greater the 
pain ; for you will have pain. Be well assured that you can, 
within three or six weeks be in the regular habit of walking six 
miles a day, which will exceed two thousand miles per annum ; 
and that when you shall have reached your six miles a day, 
you will be well again, for what health and strength shall a lady 
require beyond that which enables her to walk two thousand miles 
a year, in the beautiful sunlight, over this goodly earth that God 
has given her for her flower garden!" 

"Yes, doctor, that's very fine — very fine, indeed ; and vastly 
poetical; but to walk, I repeat, kills me, and I am afraid that my 
disease will be rendered incurable." 

" Tilly-vally, tilly-vally, Miss Helen, you know nothing about it. 
I tell you that your hsematosic tissue is not in health, nor will you 
be in health, until it shall be re-established by the sun which is 
indispensable for life, by the oxygen of the air, without which 
everything dies ; by a frequent and strong induction of nerve-power 
into all your organs, your muscles, your lungs — your heart — your 
hsematosic tissues — everywhere. These are the remedies for such 
maladies as yours. You must diet aright — -you must dress aright, 
you must bathe aright, and move, and lastly you must take some pills 
not bigger than the head of a diaper-pin ; to be made of Monsieur 



SIMULATIVE PROLAPSUS. 161 

Quenesville's metallic iron. I shall give you this prescription, not 
as a drug or as a medicine, but as an element of your body; with- 
out a certain abundance of which, neither you, nor any marnmi- 
ferous creature, nor bird, nor creeping thing can live. I verily 
believe, that even a monas crepusculurh would die but for his iron. 
You ought to have found the dose in your bread and butter, your 
rice, your salad, and your chicken, daily, these two and a half years 
past. It was there, but you did not get it. I shall give it to you, 
and shall present it daily to your organs, and you shall see what 
the effect will be. Here, give me a scrap of paper. I shall begin 
the prescription in German, and end it in English; and so you 
see my caption is 

"Mit huelfe Gottes. 

" Take of Quenesville's metallic iron, one hundred grains. 

"Powdered gum Arab, and sugar, a sufficient quantity. 

" Make a pilular mass to be divided into fifty pills, and direct, 
for Miss Helen Blanque. To take one pill for a dose immediately 
after each breakfast, dinner, and supper. C. D. M. 

"Now you must take this iron regularly, and exactly, and for 
a long time. Eat plenty of bread and meat, and take one or two 
glasses of good Bordeaux wine at your dinner ; but it should be di- 
luted with w T ater. Rise early, and go to bed early. Think, w T hat is 
true, that you have made yourself sick by a silly indulgence upon 
some slight maladive sensation, which will disappear, when you 
shall again learn to act like a reasonable creature as to the care of 
your health; and I will answer for it, that you will soon be found to 
make no more complaints. 

"You have often heard of the general faith and belief in qui- 
nine as a cure of ague and fever, haven't you?" 

" Oh, yes. I know that is what everybody takes, and what all 
the world believe in." 

" Very well; I believe in it, too, implicitly; but I have quite 
as strong a belief in the power of this medicine to cure your hae- 
matosic membrane, to enrich your blood by bringing it up to its 
proper crasis, so that its figures shall stand respectively, at 790, 
137, 80, 3. And that is all you want; for when you have that, 
and are totally destitute of any organic lesion whatsoever, your 
rich and valid blood shall disengage by its oxygen, a full nerve-power 
in the brain — which, exciting life motions in due intensity every - 
11 



162 SIMULATIVE PROLAPSUS. 

where within your economy, you shall in vain try to find the point 
so big as a pin, that is not in consummate order and health and 
perfection ; and when that shall come to be the case, when the 
red tint of the butter pear shall glow on your cheek again, and 
the cherry turn pale in comparison with your lips, you shall seem 
as charming as you really are, and I will say, after good old Am- 
brose Pare, 'I dressed, and God healed her.' 

" And, now I must bid you good morning ; for it is time to 
visit some persons who are really sick, which, thank Heaven, you 
are not." 

" Stop, stop, doctor, a word before you go. I assure you that 
for more than two years I have been most unhappy, most wretch- 
ed, in the contemplation of a present and prospective ill-health. 
Nothing has pleased me — nothing given me the hope of true en- 
joyment. I have been even sensible that I was daily losing a 
naturally good and placable temper ; and becoming what a lady 
should never become, unamiable, acdriatre, tracasseuse! I be- 
lieve that I have been in some sense like Lady Macbeth — not in 
the wickedness, I hope, but in the phantasy: there is a pretty 
Shakspeare on the table; do open it at Act V. Scene iv., and 
read it for me." 

Macbeth. — How does your patient, doctor? 

Doctor. Not so sick, my lord, 

As she is troubled with thick-coming fancies, 
That keep her from her rest. 

M. Cure her of that: 

Canst thou not minister to a mind diseased ; 
Pluck from the memory a rooted sorrow 5 
Raze out the written troubles of the brain ; 
And, with some sweet oblivious antidote, 
Cleanse the stuff 'd bosom of that perilous stuff, 
Which weighs upon the heart ? 

D. Therein the patient 

Must minister to himself. 

M. — Throw physic to the dogs, I'll none of it : — 
Come, put mine armor on. — 

" There, Miss Helen — there is your quotation. I hope you will 
follow the last line, ' Come, put your armor on.' " 

" Depend upon it, doctor. I shall try to follow your advice. I 
cannot say that the conversation I have had with you, has enabled 
me to understand as clearly as I think you do, what ails me, and 
what I require for the re- establishment of my lost health and 



SIMULATIVE PROLAPSUS. 163 

spirits. Perhaps, indeed, a long preliminary study is requisite to 
the understanding of those points, that you characterize by such 
very hard words, as en — en — end-angium, was it not? and Hema- 
tosis ? yes, Hematosis, and other such gibberish. But, admitting 
that I have not learned anatomy and physiology from your dis- 
course, I at least have obtained some glimpses of the nature of 
my indisposition, and feel that from this hour forth, I shall be 
better, for I have found courage and confidence. I am convinced 
that the game is in my own hands. I know it will be a hard 
game to play, but I also know that ' lejeu vaut bien la chandellej 
and be assured I am about to play it well. In fact you have 
cured me already by opening my eyes, and cleansing my bosom 
of that perilous stuff. I thank you heartily for this visit. My father, 
who is rich, will know how to send you a good fee for it, for he 
loves me, — you know I am his only child. I thank you the more 
heartily, because you have not even once made me poke out my 
tongue ; and because, though a doctor, you have neither cut me 
with a lancet, blistered me like a Miss Marsyas, nor poisoned me 
with that detestable calomel, and oh!-ugh! castor oil! So now 
good-bye, doctor ; come and see me again. I feel that I shall be 
soon well and happy." 

Such was my conversation with Miss Helen Blanque. In 
twenty days, I met her as beautiful as a Houri; with a gait 
like Hygiea, and a cheek that might put Euphrosyne or Hebe to 
shame. C. D. M. 



LETTER XIII. 

Gentlemen: — In my twelfth letter, I spoke at large, and per- 
haps in rather a random manner, on the subject of prolapsions of 
the womb, and was led away by the train of my thoughts, to eon- 
template the state of a young woman complaining of aches and 
pains and inabilities, that are the usual accompaniments and 
simulations of the uterine displacements. I said that many pain- 
ful, inconvenient and annoying sensations are produced in the 



164 DIAGNOSTICS OF PROLAPSUS, ETC. 

female pelvis, from very different causes, which are, in their ope- 
ration on the sensitive system, the same, whatever may be the 
difference of their true causes. I also said that, for the diagnosis 
of many cases of such complaints, it is not indispensable to pro- 
ceed to the taxis as the sole means of coming at a sufficiently 
clear understanding of the disorder; and that, while I would 
rigorously insist upon the right of using all necessary and proper 
means to clear up the obscurities and difficulties that embarrass 
the decision and action of the practitioner, I should be held con- 
scientiously to abstain from any unnecessary inquiries or modes 
of inquiry. I think that a diagnosis by exclusion will in many 
diseases lead to the discovery of the truth — that is to say, a phy- 
sician ought to be able to judge the rate of all the accessible 
functions of the body, and by comparing their actual state with a 
standard of health that he knows how to erect in his mind, he 
ought to be able to say this and this and this are right; and 
so through the great catalogue — excluding all the healthy ones — 
but this and that are wrong — and they are wrong — in this or that 
especial way. Where he cannot decide in what especial way the 
deviation of the function takes place — then let him carry his 
explorations to the farthest proper extent. In my conversation 
with Miss Helen Blanque, and in the observations that I made, 
in regard to her gestures, her mode of sitting down, and of 
standing up; of walking; of the tone of her voice; her respi- 
ration, her complexion, her style of dressing, her physiognomical 
expression, her sentiments and trains of thought, &c. &c, I was 
quite convinced, that although she was affected with pains, aches, 
and inabilities, like those of the patient from prolapsus, I could 
very clearly trace them to faulty innervations, arising from defi- 
cient crasis of the blood ; and I concluded that, by exposing her 
to exercise; to the bath; by a better diet and drinks; by sending 
her. into the air — the sunlight ; by insisting upon her effecting 
those modifications in development, that can be brought about by 
a course of training, I should cure her of her complaints, with- 
out resorting to the shocking ultima ratio — the exploratory taxis, 
or the still more detestable resort of the pessarium. I also or- 
dered for her a preparation of iron, which is probably the most 
efficacious of all the ferruginous articles, and has the additional 
good property of being quite destitute both of taste and odor. 
I cannot say that my hypothetical conversation with Miss Helen 



BAD TRAINING. 165 

was able to make her acquainted with my views of her hygienic 
and therapeutical wants ; but I flatter myself, it may have suc- 
ceeded in recalling to your memory some of the many arguments 
and rationales I had the honor to present to you last winter, and 
that they disclosed to you, if not to Miss H. herself, the precise 
views that actuate me in my professional ministry over many 
such cases. How many times have I spoken to you in that way! 

Whether these views be just or not; whether I have been able 
fully to disclose my thoughts or not, this is very certain, namely, 
that I have many, many times, held conversations like that, with 
young people whom I found depressed, and indeed almost broken- 
hearted, under a painful idea that they were ruined in body, by 
a disease which, after tormenting them for a number of years, was 
destined to bring them to an untimely grave. It is a great matter, 
in the management of such a case, to clear the mind of the per- 
nicious impression, for everybody knows, (look again at my quo- 
tation from Seneca,) that the mens sana in corpore sano, is an 
indispensable condition of happiness and health. I intend not to 
deny that a good man may be calm under physical suffering, the 
most extreme. Nay! I have seen a fine fellow, dying on the rack 
of a traumatic tetanus, and rejoicing in his spasm and smiling 
forth from amidst the most horrible cramps, even of his face ; and 
glorying in an approaching death that was to enlarge his soul for its 
instant flight to Heaven. I have seen this, and more than this, for 
I have seen greater courage and peace amidst protracted and hope- 
less pain; hopeless at least, as to earthly hope; but it is true, 
nevertheless, that a thought can kill, and a conviction utterly de- 
stroy. 

The morale of the patient has as much to do with his cure as 
the calomel, the senna, or the cinchona. 

If a girl, in coming up to the age of puberty, is badly managed ; 
if her digestive organs are suffered to become permanently de- 
ranged, under a vicious course of feeding; her nervous system to 
be badly or imperfectly developed, by means of vicious habits of 
education, in exercise, in sleeping and waking, in unnatural atti- 
tudes, in the consumption of the nervous force in studies at school 
and at home ; it is reasonably to be expected that the whole future 
life will take a color of feebleness and impressionability from the 
character of the constitution acquired at the close, and true com- 
pletion of the puberic age. 



166 BAD TRAINING, ETC. 

Such a person could hardly be expected to execute the great 
and trying periodical functions included in the meaning of the 
word menstruation, without experiencing certain maladive sensa- 
tions, like those of Miss Helen, which, though simulative of, are 
wholly independent of prolapsus or other uterine deviation. Nor 
should a physician indulge the expectation of curing such a case, 
save by means of a treatment, adapted to the wants, not of the 
reproductive tissues alone, but of the entire constitution of the 
female, which has that vice in it that no alterative can cure, but 
which can be cast out wholly, by a change in the manner of one's 
life. 

One may safely venture, in general, to rely upon the evidence 
of one's senses, and we have only to look about us, to discover 
the differences as to physical power, durability and perfection be- 
tween a languishing, impressionable city miss, lapped in luxury 
and indulgence, from the cradle upwards, and a buxom, rosy 
milkmaid, who drains the udder for a dozen cows at three A. M., 
drives her own horse and cart five or six miles to market, and 
returns to breakfast at home, after having distributed to the lazy 
citizens, the precious contents of her milk-pails. 

But the languid, perceptive, exquisite citadine is, of a truth, 
the same creature as the country girl; and you know very well, 
that to exchange positions, would in the course of a year, or more, 
be to exchange characters — the languor of the one for the active 
vigor of the other — to plant roses on the pale cheek of the elegante, 
while the lily would spring where the jocund health of the milk- 
maid was too boisterous for its white blossoms before. Is not this 
plain fact? and is it not common sense too? Yet, is it not also 
true, that we doctors frequently forget to look to nature in our 
queries? peering only into our books; following a theory instead of 
following only truth ; and imitating the painter, who, instead of 
forming his landscapes in the open fields, is condemned to imagine 
the waning distance, the winding river, the babbling brook, the 
umbrageous woods, and clear transparent air ; and the form, port 
and hues of men and animals, by the yellow light of a lamp in 
the dark narrow limits of a studio, instead of filling his artistical 
imagination with perfectionings, if that were possible, of the beau- 
ties and truth of nature as seen under the true lights and shadows 
of the open day. Truly, Dr. Forbes is right, when he invocates 
a Young Physic. We want a young Physic, a vigorous, active, 



quenesville's iron. 167 

healthful youth, born, indeed, of the ancient Gamaliels, but nursed 
and brought up in the lap of nature herself; the heir and suc- 
cessor, in this modern age, of the old time-worn Physic of our 
forefathers. 

I told Miss Helen that if any confidence might justly be 
had in the power of sulphate of quinine to cure an ague, I had 
equal trust in the power of chalybeates to cure the diseases of the 
blood, describable under the name of Ansemia; and I accordingly 
gave her portions of Quenesville's metallic iron. 

Allow me to say a few words to you on this subject. 

Quenesville is a Paris pharmacien. He places in a porcelain 
tube, a quantity of protoxyde of iron. The tube passes through a 
furnace heated to redness. He disengages hydrogen and con- 
ducts it into one end of the tube, the other being left open. The 
hydrogen unites with the oxygen of the iron and flies off as water ; 
leaving the metal revived, and existing in shining microscopic 
particles of pure iron, impalpably fine. This pure powder of 
the metal unites with any of the acids of the gastric solutions, and 
is the most efficient of the chalybeates that I have met with. I 
believe that two grains are enough, if taken on a full stomach, that 
is to say, immediately after each meal. When made into pills 
with gum, it is both tasteless and inodorous. 

I conceive that we have not, and that we cannot ever reason- 
ably expect to have any very clear notions as to the methodus 
operandi, as it is called, of any medicine. Who can explain the 
cathartic power of jalap, as contradistinguished from the emetic 
force attendant upon the chemical constitution of the calicoca 
ipecacuanha, or the tart, of antimony and potash? We are well 
acquainted with the facts, the phenomena ; and we can count 
upon our power to make them manifest under our prescriptions ; 
yet to say why tartar emetic shall produce vomiting, while sul- 
phate of magnesia shall have the effect of a purgative, is beyond 
the power of the human mind. There is something metaphysical, 
and not purely physical in the case, and we cannot seize upon the 
metaphysical element, because we cannot go up to the fountain 
head to know truly what Life is ; which can only be fully known 
to the All-wise mind. The differences in the two operations are 
differences of perceptivity in the organs ; but perceptivity is a 
metaphysical, and not a purely physical force. 

No man can know, then, more of the power of medicines than 



168 medicines; their power. 

the facts of their force made manifest in their operations. I do 
not pretend to know why it is that iron dissipates, like a coup de 
theatre, the whole train of evils concomitant on the state which I 
call Ansemia. But this I do know, or at least I think I know it, 
that when a person labouring under anaemia is submitted to my 
control, and who has no organic lesion that I can detect, of the 
great organisms of circulation, oxygenation, and gastro-intestinal 
digestion, I look forward with an undoubting confidence to the 
cure, which I expect to see begun within a few days, and com- 
pleted within some twenty-one days or thereabouts. 

I do not consider myself as credulous in believing that iron has 
a special power to invigorate the tissues composing the hsematosic 
membrane, the membrana vasorum commune ; certainly not more 
so than ten thousand American physicians, who confidently 
administer five or twenty grains of calomel with the utmost cer- 
tainty of exciting the liver into greater or more healthy activity ; 
squills to excite the mucous follicles of the bronchi ; nitre to 
arouse the kidney ; or belladonna to stimulate the skin ; and 
strychnia to wake up again the torpid muscle of a paralytic leg or 
arm. In methodus operandi of medicines, and drugs, all our 
cognitions are purely empirical — the results of the experience and 
observations made by mankind in a series of centuries, an innu- 
merabilis annorum series, et fuga temporum. 

Do you ask a further explanation of the confident tone with 
which I speak of health to be restored by restoring the crasis 
of the blood ? 

Why what else is health if that be not it which depends on 
perfect solids and perfect fluids ? What is the blood ? What its 
use, destination or design, in the body ? It is the chaire coulante 
(the fluid flesh) of Bordeu. When the chaire coulante comes to 
be fixed, it is the chaire solide — but the blood is more than that, it 
has a higher function still ; it is the direct agent in extricating 
the life-flash ; the nerve force ; the excito-motive power ; the life 
itself. 

Dr. L. Cerise, in his prize paper, in the Mem. of the Royal 
Acad, of Med., on " The Excitation of the Nervous System" says 
at page 294, vol. 9th, " Every instance of nervous-excitation is 
therefore a result of the concurrence of a sanguine with a nerv- 
ous element. Hence every sample of excitation may be repre- 
sented by a product formed by the contact of these two elements." 



DR. CERISE. NEUROSITY. 169 

Dr. Cerise proposes to denominate this product, this result, by 
the word neurosity. I cite Dr. Cerise's words, as I wish you to 
understand that I disagree with him in his opinion that the re- 
sult is the product of contacts of blood and nerve matter. For 
I adhere to the opinion I have so often expressed to you that the 
product is the result of the contact of oxygen (of the blood) and 
nerve-matter. Black blood, blood without oxygen, cannot pro- 
duce the result. There is no neurosity developed in true, com- 
plete asphyxia or cyanosis, though the brain is gorged full of 
blood. 

The brain and nerve are the creature ; the animal; the percep- 
tive being. It demands two conditions of existence, to wit : the 
substance of brain — the neurine — and the oxygen, whose contact 
and immiscence with it extricate the power. Give to the brain 
the oxygen, and the force is present ; diminish the oxygen, and 
the force is lessened ; take away the oxygen wholly, and force is 
gone — it is death. 

But a watery and ansemical blood cannot carry sufficient endow- 
ment of oxygen. None but a blood whose crasis is true, — just, — 
normal, — can carry to the neurine the true, just, normal amount 
of oxygen ; or extricate from the neurine by its action on it, the 
true, just, normal sum of innervative or excito-motive power. 
Such are my views. Such is my physiological explanation. Such 
are the motives that lead me in my walks to desire to cure the 
solids first, and then to find the fluids cured. 

I am not a Solidist, nor a Humoralist, but I am Eclectic in pre- 
ferring the best and most rational theorems of both the schools. 
I shall make no further remarks in this letter, which, perhaps, you 
will consider as sufficiently visionary, on the theory of ansemical 
disorders, remarks into which I have been perhaps prematurely 
led by remembering the considerable number of persons who have 
recovered from symptoms and accusations of prolapsus, without 
recourse to the usual remedies of prolapsus. I shall in a future 
letter enter into fuller statements of the views I have long held 
on these topics, and which I have so often discussed in your 
hearing at the Lecture room. I beg you to understand that my 
hypothetical conversation detailed in the last letter, is not very 
different from many long conversations I have had with patients, 
situated as the imaginary patient Miss Helen Blanque was. 

Farewell. C. D. M. 



170 PROLAPSUS UTERI 



LETTER XIV. 

Gentlemen : — I am still to treat of prolapsions ; I mean not the 
simulative descents of the womb, but those clearly decided cases 
of malady, proceeding from weakness and relaxation of the support- 
ing tissues, and involving the patient in distress and inconveni- 
ences arising from the traction and distortion of important nerves, 
and bundles, and filaments of nerves, and from pressure upon 
points unaccustomed to it, and unsuitable for it. 

In these cases the remedy is mechanical ; it consists in adjust- 
ing beneath the descended womb an instrument which lifts it up 
to its proper height or level within the pelvis, and maintains it at 
that natural situation until the tone, the strength of the tissues can 
be restored by time and by remedies. 

The comfort desirable from this method of support, is scarcely 
describable. A woman who for months had been unable to 
walk, or even to stand, without an ineffable sense of weakness 
and pain, moves freely and spontaneously after the adjustment ; 
and in short, is as greatly relieved as is the man who has his 
humerus reposited after a dislocation. To show you how great 
that relief is, let me tell you that I was called to a very pious 
citizen, who dislocated his humerus into the axilla, and who, 
when I arrived, was holding the right arm in an elevated position, 
by means of the left hand, with which he supported it; as the 
least descent of the elbow gave him exquisite pain. I took hold 
of the limb, made the extension in the proper direction, and then 
depressing the elbow, reposited the head of the bone in the 
glenoid cavity. As the orbicular head took its place, he ejacu- 
lated with the utmost unction, " Bless the Lord, oh my soul ! and 
all that is within me, bless and magnify his holy name!" He 
had occasion to ejaculate his thankfulness, for he passed from 
agony into perfect calm. It is true I have never heard a female 
make such an ejaculation upon a repositio uteri, — but I doubt not 
the relief has many times been almost as great in the one case as 
in the other. 

Pessaries are as various as the ingenuity of the doctors, and 



JOSEPH WARNER. PESSARIES. 171 

sometimes, of the patient herself. Most of those used here, are of 
blown glass, and consist of globes from an inch and a half to 
two and a half inches in diameter, or else of concavo-convex 
discs, about the same size. 

The best of our pessaries, however, have been for many years 
constructed by Mr. Joseph Warner, gold and silver-smith, No. 16 
Merchant Street, Philadelphia. 

■ Mr. Warner is an admirable workman, and produces articles 
of this sort of the most perfect construction. The material is 
hammered silver ; gilt, either by fire gilding, or by the galvanic 
process. 

Silver is preferred in the manufacture, on account of its hard- 
ness, which enables it to be reduced to the thickness of letter 
paper, while retaining its firmness, which could not be expected 
of so thin a plate of gold. While it is lighter, it is also less costly 
than gold. A globe of two inches in diameter, thus formed, 
weighs not more than two scruples, and when polished and 
covered with a sufficient coating of gold, possesses properties pre- 
ferable in practice, to one of pure gold, inasmuch the lighter an 
instrument of this kind, the less objectionable is it. The same 
material is employed in the fabrication of the discus, the ring, the 
elytroid, and the horse-shoe pessary, as well as the olive of the 
stem pessary, from out of the whole great number and variety of 
which you can select, according to your opinion of the indication. 
Mr. Warner could readily supply your wants in his line, through 
the various express companies established here for parcels-deli- 
very. Should you have occasion, therefore, to use any of his instru- 
ments, your letters, with description of the kind of instrument 
required, would probably meet his prompt attention. It would be 
only necessary to order a globe pessary of one and three-quarter 
inch diameter, or two inches, or two and one-eighth, &c., or a flat 
pessary, or a ring, &c. There are few towms in the United States, 
that are not reached, almost with the rapidity of the mail, by the 
Express lines of Adams & Co., Harnden & Co., &c. &c. 

The object to be gained in employing a pessary is the eleva- 
tion of the uterus to its proper level in the pelvis, and the maintain- 
ing of it in situ naturali. Many of my friends prefer the discus 
or the horse-shoe, the ring, &c. The late Dr. Dewees, invariably 
I believe, made use of the discus, commonly in this city called 
Dewees' pessary; and his deserved reputation as a practitioner, 



172 

gives to the instrument of his choice a great vogue, so that multi- 
tudes of them are made and sold. 

The equally distinguished Professor, the late Dr. Physick, who 
seemed to me, in his lifetime, almost never to be in error in any 
surgical or medical indication, as invariably preferred the globe, 
very generally known as Dr. Physick's globe pessary. In a con- 
versation I had with him, some years before his lamented death, 
(such men ever die too soon,) he told me, that while he was dress- 
er at Guy's Hospital, under John Hunter, he had charge of a 
female under prolapsus, who was treated by a discus pessary, 
having the usual perforation ; that a portion of the os uteri had 
slowly engaged itself, and become strangulated in the aperture ; so 
that he had difficulty in extricating it, an accident which I also have 
witnessed more than once. As he would not venture to expose 
the woman to a second strangulation from the same ill-constructed 
pessary, and as an old billiard ball that had been some time in the 
ward was at hand, he adjusted it beneath the uterus. The new 
application succeeded so admirably in sustaining the organ, that 
the Doctor ordered globes to be constructed, and we are, I believe, 
truly indebted to him for the beautiful and valuable resources thus 
placed in our reach. Such is my understanding of the history of 
the globe pessary of Dr. Physick. 

As to my own preferences in the matter of pessaries, I have 
only to say, that whatever may keep the womb at its due height 
without irritating it, or incommoding the other organs and textures 
implicated in the descent, is a good pessary; but I deem the globe 
the most perfect and most suitable for the ordinary simple cases. 
An instrument of two inches, pressed upwards to the uterine ex- 
tremity of the vagina, lifts the womb high enough ; higher in fact 
than the position occupied by it in eight out of ten of those women 
who have had a child, and that is high enough. It is kept up by 
the double and consentaneous actions of the sphincter vaginae 
muscle, and the levator ani. It has no angles, no sides; it can- 
not be displaced, save by being ejected. Its pressure is uniform 
over its whole superficies, save where its lower segment looks 
down the tube of the vagina. This cannot be so truly said of any 
other instrument, if we except, perhaps, the gum-elastic bottle, 
used and recommended by Dr. Hervez de Chegoin, in his paper 
in the Mem. de VAcad. Roy. de Med. The globe has a perfect 
polish, and an unoxydizable surface. It may be worn a year or 



PROLAPSUS. PESSARY. 173 

more without displacement, if required ; and it has no aperture to 
admit of the collection of putrescible materials within it. It does 
not prevent the escape of the mucus of the uterus and vagina, 
nor of the menstrua ; and in short, is the least uncomfortable and 
most perfect of instruments. It is a true suspensory, as needful 
for the descended womb as the suspensor scroti for a hernia 
humoralis or orchitis. It is as neat and perfect in its kind, as 
Petit's tourniquet in its kind, and as indispensable for the cure. 
Dr. Physick used to tell us in his Lectures, that a man might as 
well attempt to improve the Bible as Petit's tourniquet, and I, 
after him, repeat, that you might as well attempt to improve Petit's 
tourniquet, as Physick's globe pessary. But you know I always 
have warned you to be Nullius addictus in verba jurare magistri, 
and so I say, judge of it for yourselves. 

Can a man expect to cure a prolapsus by the use of the pessary? 
Yes, provided there be no loss of substance. A woman who in 
labor, has lost the perineum by the effect of laceration or slough- 
ing, may be held to have lost also, all useful function of her leva- 
tor ani, and there is no hope, therefore, of a permanent cure of the 
tendency in her to prolapsus; since, in fact, the perineum, the 
normal antagonist of the diaphragm and abdominal muscles, is 
taken away from her, giving to the antagonism alone, supreme 
and unresisted power. Such a woman can expect to provide only 
an artificial antagonism, w T hich you can always furnish her with, 
by means of the stem pessary, to be hereafter described. 

Those females, however, who labor under prolapsion from the 
mere descent of the vagina, arising from its relaxation or loss of 
tonicity, can be cured by the pessary. I take it for granted, that 
every living tissue has an inherent tendency to contract, and 
when that tendency is not carried out into execution, it is because 
something resists, antagonizes, prevents it from obeying its law. 
To support, then, a vagina at its normal elevation within the pelvis, 
is to take away the resisting antagonizing preventing cause, and 
to allow it, with time, to recover its normal density and solidity. 

I mean not to say that this is always the sole thing needful to 
the cure; but I do suppose that it is in many instances the only 
chirurgical or medical process demanded, since the freedom from 
pain or inconvenience that follows the timely application o( a 
proper pessary sets the woman free from the bonds of her symp- 
toms, and enables her to take advantage of the restorative power 



174 PROLAPSUS. CURE. 

of diet, air, exercise, bathing, traveling, and other hygienic 
methods, the wise and prudent employment of which may be 
expected to repair the mischief of debility and relaxation not as 
to the vagina alone, but as to every part and parcel of her living 
system. 

Where the woman's general health, however, is broken, and her 
great alimentary, respiratory and circulatory functions overthrown, 
we should gather by careful inquiry and observation the indica- 
tions of treatment, and pursue them to a subduction of the special 
evil or evils. A woman may have bad health from deranged 
action of the chylopoietic organs, requiring the exhibition of blue 
pill, taraxacum, alkalies, nitro-muriatic acid, eccoprotics, or even 
purgatives. She may have neuralgic or neuropathic affections 
springing from a vice in the hsematosie tissues, from exaggerated 
vital sensibility of the heart, &c. In all these varieties of com- 
plaints, whose name is legion, let the especial sin be found out 
and eradicated. 

The bitter tonics, bark, wine; the chalybeates ; a trained 
health ; the exact indication of the diet as to quality and quan- 
tity ; the amount of wine, malt liquor, &c. : these are the pro- 
blems you are to solve, and upon their correct solution depends 
the question whether you are to have the great satisfaction of 
seeing your patient restored to health ; or whether she, by a 
dawdling, indeterminate course of counsel and prescription, is to 
be left to drag out the weary years of broken health, lapsing from 
one evil to another, until, under the first serious attack of disease, 
she falls the victim of what is truly denominated a broken consti- 
tution. Who broke that constitution ? The disease, by its vio- 
lence, or the Doctor, by his want of foresight, zeal, and intelli- 
gence? 

The pessary, then, is to be regarded as the suspensory, as the 
splint, as the bandage — and, in truth, as happens in many other 
cases in surgery, these are the only indications. But, as in sur- 
gery, you would not, perhaps, treat an orchitis solely by the sus- 
pensory, but would make certain prescriptions, with a view to 
abate constitutional or local derangements of the circulation, the 
absorption, or the innervations of a part, so in the management of 
the prolapsions, you might not rest content with the curative 
power of the pessary alone, but provide the other juvantia of 
which I have already made mention. 



PROLAPSUS. PESSARIES. 175 

How long shall a woman wear the pessary? An important 
question, that cannot be solved but upon experiment. Several 
months will in general be required in any case, because the 
fastidious delicacy of a female will always prevent her from dis- 
closing to you her distress in its early stages, and you know that 
chronical disorders are more difficult of cure than recent or acute 
ones. Hence I repeat that the cases that may come under your 
care, are very likely to prove tedious and protracted. They will 
be mostly chronical. 

It will be a part of your duty to keep up a strict surveillance 
of the patient under treatment. It will be a duty to receive her 
report from time to time as to the operation of the instrument. 
You may become convinced that a larger or a smaller one is indi- 
cated ; and always, where you can believe that a reduction of 
the diameter of the instrument is admissible, that ought to be 
done, on account of the less inconvenience to be suffered by the 
tissues under a less degree of distention and pressure. I esteem 
it a very great fault on the part of the medical man, to adjust a 
pessary for a female, and to send her away without very plenary 
instructions as to the conduct of the subsequent steps of the cure. 
Women sometimes have wholly forgotten them, and allowed them 
to remain for a series of years, until the instruments, having become 
spoiled by age, or the action of the acids of the parts, have rusted, 
opened, and admitted into their cavities the most shocking collec- 
tion of putrid humors. I have removed several such for persons, 
who had neglected themselves for years, and thus become exposed 
to the danger of putrid infection from materials kept in a state 
of decomposition in the interior of their bodies. Pray turn to 
the 145th page of Colombat, and read the foot note, for the case 
of the Baroness de Carl . . . , who was supposed to be laboring 
under a cancer of the womb. This lady was suffering from a 
pessary that had been introduced thirty years before. It was 
thickly covered with calcareous incrustations that could not but 
irritate all the parts touched by them. I am acquainted with a 
lady who suffered under uterine and vaginal hemorrhage, with a 
frightful, stinking leucorrhoea. The surgeon who had adjusted 
the instrument ten years before, as well as the lady herself, had 
forgotten it. The treatment was all in vain, until, upon making 
his taxis, he discovered the cause of the malady. Its removal was 
the indication. The indication being fulfilled, the disorder dis- 



176 PROLAPSUS. PESSARIES. 

appeared, after having reduced the fine woman very near to the 
grave. 

There is another reason why you should overlook the operation 
of your pessaries; and that is, that their pressure, in some in- 
stances, is followed by absorption and ulceration of the parts com- 
pressed. There are plenty of samples in the records, of pessaries 
that, by neglect, have forced their way into the rectum, compelling, 
by long pressure, the absorbents to remove the recto-vaginal sep- 
tum ; so that, a part of the instrument resting in the vagina, an- 
other part of it forced its way into the bowel, establishing thus a 
recto-vaginal fistula. The same catastrophe may happen as to 
pressure in another direction. The bladder may be opened, and 
even bladder, vagina, and rectum may be and have been made 
to communicate with each other, by the ignorant or careless em- 
ployment of these excellent instruments. I am very sure that 
such distressing occurrences will never follow your ministration 
in this line, since I indulge the hope that you will never fail to 
do your whole duty, which is, after adjusting the apparatus, to 
make the woman clearly understand what she has a right to ex- 
pect, and what she ought to do, in reference to the remedy. 

You would not be apt to suppose that a woman, who had long 
suffered the pains, &c, of prolapsus, and who should be completely 
relieved of them by wearing a pessary for three, six, or twelve 
months, could dispense, at once, with the suspensory instrument, 
without finding reproduced some of the annoying sensations which 
its presence had rendered impossible. Therefore, whenever you 
conclude to remove the support, she ought to be informed that she 
will experience some return of the strange feelings, and thus be 
led to fear she is not cured. The fear of this, is the motive for 
advising you to substitute a smaller for a larger instrument, and so 
on at each consecutive change, until the patient is quite able to do 
without them altogether. Or, if you be prompted by any motive 
to desist from the further employment of the support, you cer- 
tainly ought not to do so, until, by a proper aperient dose, you have 
cleansed the alimentary passages of their contents; and then, taking 
away the pessary, command that the patient should keep her bed 
for a few days, in order to obviate the pressure and descent of the 
pelvic contents likely to take place upon the sudden withdrawal of 
all antagonism — the patient being not only on her feet, but en- 
gaged, perhaps, in occupations of a laborious or fatiguing kind. 



SUFFITA. SACHETS. 177 

I verily believe, my young friends, that you have now not the 
intelligence only, but the means, apparatus, and authority required 
to enable you to effect a certain and durable cure. If you do not 
effect that cure, the fault will lay at the door, not of the malady, 
but at your door for carelessness, or at the woman's, for obstinacy 
and folly. 

The ancients were in the habit of employing for these maladies 
many medicated pessaries, which though really pessaries, were 
also deemed to be suffita or fumigations. It is probable, that 
among the host of old methods, were some very effective ones, 
now become wholly obsolete in the elegant practice of the metro- 
politan physicians. I think I have in my lecture room, advised 
you not to omit in your armamenturium, the sachet or little bag, 
recommended by Levret, and, indeed, by Hippocrates and his 
descendents down to this very writing. 

When your patient shall have discarded her pessarium, let her 
construct half a dozen small cylindrical bags as big as the thumb. 
They should be made of good linen, and should be packed full, 
very full of finely grained, not pulverized Aleppo galls, to which 
may be added a few grains of sulphate of quinia and alum. The 
bag may have a short bit of tape or a little loop of tape secured 
to its lower end. If soaked, for an hour or more, in some common 
rough claret or weak port, then pressed and dried in a napkin, 
and dipped in sweet oil, it can readily be introduced into the 
vagina as a medicated elytroid pessary. It does not inconve- 
niently distend the vaginal walls, which it tends to strengthen, 
enhancing their tonicity by the medicinal articles contained, while 
it elongates, or produces the vagina, and thus supports the womb 
in situ. 

A sachet adjusted in the morning will not escape, if the patient 
wears her napkin ; and it might very safely be allowed to retain 
its place for four or six consecutive hours, more or less, daily, for 
an indeterminate period. 

These medicated sachets are of very great value in the treat- 
ment, not only of the relaxation and fall of the vagina, but also, 
as agents for suppressing the too abundant excretions of the follicles 
and glandules of the mucous membrane. I am surprised that 
they are not more commonly resorted to in the United States. In 
addition to the materials I spoke of, they can be compounded, 
with proper proportions of cubebs, opium, kino, krameria, oak 
12 



178 SPONGE. CORK. CAOUTCHOUC. 

bark, &c. &c. If you will take my advice, you will not reject 
them from among the resources of your art. 

Half a dozen of them, prepared by the patient herself, who is 
supposed to be never disjunct from the needle and scissors, would 
last as many days. 

I am hardly willing to burthen these letters with descriptions 
of the other sorts of pessaries. Yet I ought, perhaps, to protest 
against the sponge, most particularly against the sponge. It is a 
tampon. I have, in my long lifetime, had too many occasions 
to use the tampon, not to have learned what a foul and fetid thing 
it is after having passed only twelve hours, bathed in animal fluids 
at a temperature of 95° or 96°. I protest against its employment 
as a pessary, not only on account of its irremissible fault of un- 
cleanness, but for the additional objection of its irritating nature; 
the points of the sponge could not fail to vex and fret the mucous 
tissue of the vagina. 

Pessaries are also made of pieces of cork cut into oval or cir- 
cular discs, and dipped repeatedly in melted wax, until a sufficient 
coating of the wax being imposed, they are adjusted beneath the 
uterus to retain it at its due height in the pelvis. Similar instru- 
ments are also prepared by coating a tissue with varnish consist- 
ing of boiled linseed oil, after the manner of the French bougie 
or catheter. They are also objectionable as liable to change, and 
to infiltration. The wax coming off from the cork, leaves its scab- 
rous surface in contact with the living tissue of the womb or vagina, 
to their great damage or ruin, while the accumulation of putresci- 
ble fluids about them might well serve to provoke the attack of 
dangerous fever. 

You will find a capital, cheap, and commodious pessary in one 
of the little caoutchouc bottles that you can buy for ten or twelve 
cents at any of the apothecaries. This is the pessary recom- 
mended by Dr. Hervez de Chegoin, in a paper on retroversion, 
read at the Royal Academy of Medicine, and which I have already 
spoken of. 

Procure such a gum-elastic bottle, about two inches in diameter, 
and without cutting off the neck, pack it full of finely-carded wool. 
Take care merely to distend it well, not too much, for it is desira- 
ble to have it very soft and elastic. After filling it so as to give 
it permanently the requisite form and size, be very careful to tie 
up the neck of the bottle so securely as to remove all danger of 



CAOUTCHOUC. WHALEBONE RING. 179 

the wool being penetrated by the excretions of the vagina. If you 
allow those fluids to get inside of the bottle, they will suffer a 
horrible putrefaction. Leaving the neck sufficiently long, the 
pessary will maintain its position, because the cylindrical neck 
being directed towards the os magnum, will keep the instrument 
steadily in situ. You can cut a solid piece of caoutchouc into 
the shape of a phial-cork, and stopping the neck of the bottle with 
it, secure it there with gum-elastic cement, which seals it her- 
metically. I prefer the stuffed one to the inflated one of Doctor 
Hervez. 

It may be worn long without changing. It is soft, light, elastic ; 
and, therefore, suitable for some cases in which the metallic resist- 
ance of the globe or ring, or elytra, would be painful. For the 
poor it is cheap — and perhaps it is, on the whole, nearly as good 
an instrument as a silver-gilt one. These bottles have a neck from 
half an inch to three-quarters of an inch in length. If you should 
prefer one of them, after you have filled the bottle with carded 
wool, which you can press into it so as to give it any shape you 
may prefer, should you have no gum-elastic cement at hand, you 
might put a short velvet cork in the neck of the bottle, and draw- 
ing the gum-elastic over the cork, tie it so as completely to ex- 
clude the air and to prevent the entrance of any of the fluids of 
the vagina within the bottle. The neck of the bottle being 
directed towards the vulva, there is no risk of the instrument 
changing its position. 

I had some time charge of the health of an old lady here. She 
was 85 years of age, and had long endured the inconvenience of 
a procidentia. The perineum and the levators were without 
tonicity, and no globe nor disc could she wear, as they instantly 
escaped oji account of the relaxation of all the parts. She was 
for years of her decline made comfortable, as to her prolapsus, by 
means of a ring pessary. 

She took a long slender whalebone, bent it into a ring of near 
three inches in diameter ; then wrapped it, or as the sailors say, 
served it with bobbin, so as to give it proper size and firmness. 
She then dipped it in melted wax again and again, until it was 
completely and sufficiently coated with the wax. This ring she 
adjusted within the vagina, and maintained by its aid the womb 
in the pelvis. 

Another woman employed a common umbrella ring for her 



180 DIAGNOSIS. 

prolapsion, and wore it for years a Pinsgu de son marl. It might 
happily have been denominated the Gyges pessary. 

Pessaries are never to be introduced except after a careful in- 
quiry with a view to ascertain the state and wants of the tissues 
affected. A gentleman informed me, in the street, that he had 
a very singular case of prolapsus uteri — that the vaginal cervix 
was enormously swollen, and that he had in vain tried repeatedly 
to discover the os uteri. He feared that some very extraordinary 
state of things must be present to alter so completely the form of 
the parts. 

" What are you doing for your patient ?" said I to him. 
" Why, I have tried the pessary, but without any success. She 
cannot retain it at all; it comes away, and, moreover, gives her 
great pain." 

" How are her strength and health?" 

" Oh, very weak; she has the most violent menorrhagia, and 
has become, in consequence of it, much reduced and perfectly 
blanched." 

"Go," said I, "to your patient again, and make a careful ex- 
amination. You shall find that your enormous cervix uteri is not 
a cervix, but a polypus that fills up the vagina — that bleeds, and 
that has no os uteri." 

He took my counsel, repeated his diagnostic exploration, and 
came to say that it was truly a polypus. Upon the extirpation of 
the tumor by means of Gooch's double canula, the hemorrhages 
ceased, and the lady recovered good health without any prolap- 
sion. 

I relate this case for your warning ; because the gentleman 
who made the mistake, is a person of the most elaborate medical 
education, both theoretical and clinical. You, who are young 
and inexperienced, will be vastly more likely to make such 
bevues than he. And indeed ! it is curious to think how many 
strange, ridiculous misapprehensions one meets with among the 
brethren in regard to women's maladies. It seems to me that 
the delicacy of the relations existing between the sexes must 
have the effect of blinding some persons to the plainest and the 
most diaphanous truths and facts. 

There is a kind of pessary, called the pessary en bilboquet by 
the French, but which is properly, in English, denominated the 
stem-pessary. Such an instrument is indispensable for the com- 



dr. blundell's pessary. 181 

fort of those who, having lost all sphinctorian, elevative, and peri- 
neal force, can not retain within the walls of the pelvis, either 
the reproductive organs, or the fine instruments introduced to 
serve the purpose of an obturator or diaphragm. 

Dr. James Blundell, of London, furnished such an instrument 
to a patient of mine, who had long suffered with prolapsus and 
retroversion. 

It consisted of a gilt pear-shaped pessary, about one and a half, 
by three-fourths of an inch in diameter, screwed on a small gilt 
cylinder, the size of a writing quill, and three and a half inches 
long. This was the pessary. Now the frame on which the pes- 
sary was supported, was a hard silver wire, twelve or thirteen 
inches in length, bent so as to bring its extremities together, 
which were secured with hard solder. The wire ring thus made 
was reduced to the form of an open parallelogram, the angles 
being left rounded, and a cross piece of silver being adjusted 
across the middle of the wires, constituted a bed into which the 
free extremity of the pessary stem was screwed. The flat bar 
was three-fourths of an inch long, by one-fourth in width. The 
wire frame was bent so as to make it fit the curve of the inferior 
part of the trunk of the body ; more or less, according to the em- 
bonpoint of the patient. A girdle of suspender-web was fastened 
round the hips just below the cristas of the ileum, and straps of 
leather attached to each extremity of the wire frame, were fastened 
by the hook and eye to the girdle. 

Such an apparatus can be worn with little inconvenience, after 
a day or two of habituation ; and the vagina can be extended, car- 
rying the uterus before it to any desirable length. Patients who 
have employed it, have been relieved of uterine deviations that 
would not yield to the globe, the discus, or any other treatment. 
The greatest objection to this instrument is its costliness, for Mr. 
John Rorer, of North Sixth street, who has prepared several at 
my request, informs me they cannot be sold at a price under fif- 
teen dollars each. 

There is another pessary in use here, fashioned somewhat like 
a horse-shoe, either furnished with the corks, that is, by bending 
the heel of the shoe, or without the corks ; I have never used this 
instrument, nor shall I employ it, since I cannot deem it safe to 
allow the points of the horse-shoe to be the points of resistance 
to the whole tenesmic or bearing down power. Such a point of 



182 PROLAPSUS IN THE UNMARRIED. 

pressure is too small. Indentation is followed by absorption ; upon 
the same principle as that which causes what is called the bed- 
sore ; and ulceration of the compressed points gives insufferable 
pain. 

Having now said all that it is obvious for me in this letter to 
say on the subject of simple prolapsus, and the use of pessaries, 
and their kinds, I shall proceed now to recapitulate my views on 
the disorder — 

1. Prolapsus uteri is a disease of the vagina, not of the 
womb. 

2. To cure prolapsus uteri, you are to seek to cure the vagina, 
and when you have done that, the womb will be found cured 
also. 

3. The pessary is a suspensory, which in the cure of prolap- 
sus, is as necessary as a suspensory is for an orchitis. 

4. I prefer, as a general proposition, the globe, to all other 
forms, and Dr. Physick's globe pessary to any other. 

5. If you apply the pessary in cases not suitable, you will do 
mischief. There ought to be no inflammation nor ulceration either 
of the vagina or the w T omb. 

But I defer to my next, some further remarks on the use of the 
pessary. C. D. M. 



LETTER XV. 

PROLAPSUS UTERI. 

There are certain other circumstances connected with prolap- 
sus uteri, that I ought to notice, as supplementary to the observa- 
tions contained in my last letter. 

The question arises as to the treatment of prolapsus in the 
unmarried female, and I may observe, that I have been many 
times asked by my friends of the profession here, whether I had 
met with prolapsus in young unmarried women, and if so, how T I 
had proceeded in the treatment of them. 



PROLAPSUS IN THE UNMARRIED. 183 

Now you will have observed, that in the former letter, I have 
averred that prolapsus uteri is an affection of the vagina, and not 
of the womb itself, and that to cure prolapsus uteri, you should 
direct the resources of your skill to the curing of the canal, and 
curing that, you would find the womb, ipso facto, cured also. 

I do not entertain any doubt as to the correctness of this opin- 
ion, and often I have, in an otherwise healthy, strong, and well 
developed female, still a virgin, found the os uteri so depressed, 
as to touch the posterior surface of the membrana hymen. 

The effect of long- continued tenesmus, connected in its origifi 
with a costive condition of the rectum, and the accompanying 
urinary tenesmus, might well be deemed enough to shorten by 
degrees the vaginal tube, and thus allow the womb to settle down 
to the very hymen itself, as in the cases referred to. Long-con- 
tinued irritation from hemorrhoidal disease and from catarrhus 
vesicae — from an habitual pruritus vaginae — a sedentary life — 
might reasonably be expected to produce the same state of things 
as to the vagina. 

In the conduct of such a case, I should not deem a medical 
man warranted upon a mere suspicion, that the distress com- 
plained of, had its origin in a uterine descent, to institute a vagi- 
nal taxis. On the contrary, he ought to endeavor, by therapeuti- 
cal measures, to obviate the distress. Fortunately these measures 
are sufficiently numerous and prolific, if well chosen. They are 
1, a free venesection ; 2, the operation of a few doses of some safe, 
but active purgative medicine, such as the compound powder of 
jalap and cream of tartar, repeated on alternate days for four or 
five doses ; 3, an enema of forty-five drops of laudanum in a fluid- 
ounce of starch water nightly, upon going to bed ; 4, rest in a re- 
cumbent position for a week or ten days; 5, the warm bath 
repeated nightly, before sleeping, and used during two or three 
weeks ; 6, great care taken to avoid accumulation of considerable 
portions of urine in the bladder, which can be accomplished nearly 
at will by the patient, under proper instruction. 

There is good reason to expect that such a course of advice 
and consequent action, will be followed by relief from the distress- 
ing symptoms of the malady ; and that when thus in a measure, 
relieved, the young woman will be able, under a judicious treat- 
ment as to sleep, exercise, and food, to recover her health. It is 
very clear to me, that I have seen several, nay, many oi them, 



184 CASE OF PROLAPSUS. 

get well under such a course. But, to recover thus, is far better 
than to recover after having been subjected to the mortification of 
the touch. I assure you, that I have allowed a young lady to lapse 
from bad to worse until her situation had become dangerous and 
to the last degree alarming to her friends, rather than expose her 
to such vexation. I shall report to you a case of this sort when 
I come to speak of menorrhagia. 

In one person, aged about thirty-five, who had been long ren- 
dered miserable and inefficient in the performance of her duties, 
consisting in earning her own support and that of her mother, I 
found the os tincse jammed against a strong hymen. As the 
Sieur de la Motte informs you in the extract at page 128, I could 
readily push the os uteri away from the membrane on pressing 
my index finger through the opening ; but as soon as I withdrew 
it again it came back to its old place where it had long rested, 
in consequence, I suppose, of her sedentary habits, and the torpor 
of the rectum attendant on such habits. It was necessary to cure 
her of a disabling pain. I therefore pushed the uterus out of 
the way as far as I could ; that is to say, I made the vagina as 
long as I could make it by pressing the point of my finger on the 
os uteri, and thrusting it slowly as far as I could reach ; but this 
operation could not cure the patient, for, as the knight of Valognes 
saith, "il revient aussitot qu'on a ote son doigt." 

I had no other recourse, therefore, than to the employment of a 
suspensory apparatus. The suspensory that I chose, was Dr. 
Physick's globe pessary. I do not remember the size of it, but I 
presume it might have been one of an inch and seven-eighths in 
diameter. This globe, being slowly and gently pressed into the os 
magnum, after being dipped in a cup of olive-oil, ascended in the 
vagina to a sufficient height to produce that organ, and restore its 
long diameter. You should observe that such an instrument does 
not rest at the lower end of the canal ; for in fact, it is pressed up- 
wards, by the contraction of the muscular fibres that serve as 
sphincter, and which in some women are so strong as to possess a 
truly spasmodic force. I repeat the words, spasmodic force ; and I 
say so because I have met with more than one example of that 
spasm existing as a tonic spasm and giving rise to great pain like 
the pain of cramp ; and even preventing the accomplishment of 
the union of the sexes until overcome by treatment : and this in 
several persons of 40 and of 45 years of age, who had borne 



IMMOBILITY OF THE WOMB. 185 

children. I regard such cases as being forms of rheumatism. In 
one case here, the sphincter fibres were divided as in some of the 
tenotomy operations — the woman afterwards bearing children. 
This operation was done by your Professor of Anatomy, Dr. Pan- 
coast, who related the circumstance to me within a few days. 

I have only to remark as to my patient, that she was relieved 
of her distress. I have lost sight of her now, and am unable to 
represent to you the actual state of her health. 

In other samples of young and unmarried ladies, I have been 
compelled to adopt the use of the pessary ; but I have had less re- 
luctance in so doing where I have found the hymen wanting. Not 
that I mean to cast any reflections upon those in whom I have not 
observed signs of virginity ; for I am speaking of persons against 
whose honor and purity no breath, nor the slightest whisper of 
imputation could possibly be breathed. There are many, many 
young virgins, in whom the membrane never existed ; and I have 
a right to say so equal to the right of any other medical man of 
my age. As I have permitted myself to go so far in a discursive 
way, allow me to add, that I hope you will not be so stupid, when 
being engaged in practice, as to accuse of impurity and unchaste- 
ness, any female, otherwise worthy of your respect, because you 
may happen not to meet with this membrane. I can assure you 
that I know several persons, long married, in whom it has never 
been broken ; and among them, some whom I have delivered of 
several children, and in whom the mark of virginity is still in its 
place. Hence, the hymen is not proof of virginity, nor is its 
absence a sign of defloration. 

There is a sort of prolapsus that has this peculiarity: viz., 
that when you attempt to push the womb up to its place, you 
cannot make it recede, for it seems to be immovably fixed ; and 
this is the case described as immobility of the uterus. But please 
observe that this immovable womb is not, indeed, immovable. 

There came to me a few years since, from the State of Rhode 
Island, a gentleman, bringing his wife for my counsel as to her 
case. They had been married for some time, I think over two 
years, and had had no children. The lady suffered with constant 
pelvic pain ; also great pain in the back and hypogaster, She was 
reduced in flesh; could take no exercise; had a poor appetite; 
was costive; and had been confined to her house for many weeks 
before leaving home in the steamer for the journey. The gentle- 



186 CASE OF IMMOBILITY. 

man was in the habit of carrying her in his arms up and down 
stairs, in consequence of her weakness and her pelvic pain. 

Upon making the vaginal taxis, I found the os tincse just at the 
os magnum, and that it would recede but very little upon my 
pushing it with the palp of the finger. It was as firmly fixed as 
if it had grown fast there. 

As I concluded that all her pelvic distress was reasonably to be 
attributed to a prolapsed condition of the womb, I resolved to get it 
out of the way, and I was sure to accomplish my object ; for I 
had many times before met with this so-called immobility of the 
womb, which I had proved to my own conviction not to be im- 
movable. 

I procured, therefore, a small globe pessary, the diameter of 
which did not exceed an inch and a quarter. This pessary I 
slowly pressed through the os magnum, allowing time enough to 
permit the vagina to yield in the direction of its axis. I was a 
long time engaged in pressing the globulus into its position, and 
I did fail to adjust it to my mind's contentment ; for I was com- 
pelled to cease any further prosecution of the attempt, and leave it 
so far immerged that the equator of the ball was within the grasp 
of the vagina, yet leaving a small segment of the sphere projecting 
betwixt the labia pudendorum, that were slightly disparted by it, 
rendering it easily tangible externally. I now caused her to be 
drawn up into her place in bed, lying on the back, with an urgent 
request that she would tolerate any pain or strangury that might 
come on during the night, and holding out the expectation that 
the protracted and gentle pressure to be exercised by the con- 
tractility of the tissues, would by the next morning carry the 
ball high up into the pelvis, though it was now just under and 
perhaps, a little in the rear of the crown of the pubal arch. 

And so it happened. In the morning I found the globulus had 
been pressed completely into the more lax segment of the vagina, 
by the contractions of the sphincter and the contractility of the 
non-muscular tissues. 

In short — she began to go about the city; soon afterwards re- 
turned to her own home, and within about six months I had a 
letter asking my advice, as to the continued employment of the 
pessary, in her then condition ; as she was in the fourth month of 
her pregnancy. Of course, I advised the removal of the instru- 
ment, since which I have had no intelligence from her. 



PRECAUTIONS AS TO PESSARIES. 187 

By way of parenthesis, let me inform you that the pessary does 
not put a bar either to gestation, or to conception. I say this, 
being founded on repeated observations ; one of which, but yester- 
day, May 22d ; the woman having told me she had never removed 
the globe, though she is now enceinte. 

Why should you, then, feel any anxiety as to the escape of the 
mucous and mensual excretions ? The globe and the disc are alike 
incapable of preventing the due discharge of all the products of 
secretion, the hemorrhages, &c, that may appear beyond it. 

You would reasonably expect that the pressure, and even the 
presence of any foreign body in the vagina, and touching the 
womb, might excite an increased mucous discharge. This is a 
general consequence of the first use of such methods, but these 
newly excited discharges soon disappear. Take heed though, and 
take good heed too, that the patient shall inform you of any such 
discharges coming on at a later period of the treatment ; and par- 
ticularly if such discharge should have any, the smallest trace of 
blood mixed with it. Such an occurrence would lead strongly to 
the inference that the instrument had excited ulcerative inflam- 
mation, with purulent discharge. It is of the highest moment in 
any such case, to take away the support and carefully examine the 
parts by the speculum uteri. If the os tincee, or either of its lips 
should be found red, with visibly enlarged venules and capillaries ; 
or if any abrasion or granulations should be detected; touch them 
with sulphate of copper in solution held in a camel-hair pencil ; or 
with Goulard's extract of lead; or with acetate of zinc and wine 
of opium; or with nitrate of silver. Ten grains sulphate of 
copper, to half an ounce of water will do ; Goulard's extract and 
water, equal parts ; ten grains acetate of zinc, forty drops wine 
of opium, and half an ounce of rose water; ten grains, or twenty 
grains of nitrate of silver, to the ounce of water. These formula? 
are perhaps sufficient. 

If the vaginal cervix is turgid, red and sensitive, eight or ten 
leeches dropped into the speculum ofRecamier, will, in twenty-five 
to thirty minutes, have drawn from the cervix caught in the 
uterine extremity of the speculum, a quantity of blood, sufficient 
to lessen the turgescence of the cervical circulation. 

Surely such a patient should keep her bed or her couch until 
cured of the abrasion and inflammation. 

As to the use of the pessary. I recommend that you adopt as 



188 UTERO- ABDOMINAL SUPPORTERS. 

an invariable rule of practice, that you will not prescribe, nor 
even sanction its employment, until convinced by actual know- 
ledge, that the indication for it is there. I say so, because every- 
body knows something, however imperfect, about the pessary ; 
and every woman who has a pelvic misery, will naturally be dis- 
posed to play the quack as to her own case. If the case be one 
likely to be benefited by it, you ought to allow and recommend 
it ; but that you cannot know by instinct. Inquire, examine for 
yourself, and if there be sensibility, discharges, — and especially 
discharges of a bad color, — away with a pernicious instrument, 
which can only make the sick woman more ill, and bring into dis- 
credit a means of relief commended by the united voices of 
twenty centuries. 

And now, what shall I say of those utero-abdominal supporters, 
that you see paraded in the newspapers, and forced into vogue by 
the certificates of physicians, and proh pudor ! of Professors in the 
Schools of Medicine! 

What shall I say of them? Have you a skeleton in your office? 
I pray you open the door where the grim and ghastly representa- 
tive of our poor mortality stands, as the mocker of all human 
pride and ambition. Don't you see that if you draw a line from 
the pubis to the xyphoid cartilage, it will represent the linea alba 
of the grim horror? Look again, and observe the place where 
the mesentery was attached, and the root of the mesocolon too. 
Look down through the plane of the superior strait to see where 
the uterus was, and where grew the vagina that supported it. 

Now take a utero-abdominal supporter, and adjust it as the 
mesmerized do, mentally, upon the skeleton, and you will see that 
it can have no effect to hold up the bowels : that it can only push 
your fancied tractus of the linea alba backwards against the spinal 
column; and with what effect, pray? Surely, with none other 
than one of encroachment on the capacity of the abdomen. Do 
you not see, that the belly of a living man or woman, is a vacuum 
plenum. How can you hold up the bowels by a pad? If you 
could thrust them upwards in the vacuum plenum, which you can- 
not do, you would only thrust them towards the concave of the 
diaphragm. But the diaphragm must come down, or the woman 
will die. She can't breathe but by the descent of her diaphragm. 
Her diaphragm is her respiratory piston, and the trunk of the body 
is the cylinder in which this piston moves downwards in the aspi- 



UTERO-ABDOMINAL SUPPORTERS. 189 

ration, and upwards in the expiration of the air of the atmo- 
sphere. But your utero-abdominal Supporter knows better than 
the Providence that made this great machine; and he is about to 
make the piston work half strokes in breathing; like an engine 
that one is afraid of. No, young gentlemen! the utero-abdominal 
supporter cannot hold up the bowels; it can make the belly too 
small to contain them, and they will make haste to get out of the 
squeeze by falling down into the pelvis, where they were not 
before, and ought never to be. 

How could the surgeons of the United States and England, put 
their names, like so many notes of admiration, to such an anti-chi- 
rurgical and anli-physiological nonsense! Did they not forget 
that one-fifteenth of the human family is asserted to labor under 
hernia in some shape? And why? Because the belly is too small 
for its contents in one out of every fifteen of us, and they force 
their way of escape by the umbilical ring, by the abdominal canal, 
under Gimbernat's ligament, and elsewhere, wherever the pressure 
can force them out : yet these recommenders of an unblushing ad- 
vertisement come to put on utero-abdominal supporters, forsooth. 
I am ashamed for my cloth, when I see their names so wrongfully 
appended to a quack advertisement. I thank Heaven you do not 
see my friend Dr. Hodge's name there; and you may take my 
word, that mine shall suffer from no such use of it. 

You perceive I am not quoting in these letters a hundred authors 
to sustain me, in my instructions to the cherished members of my 
class. I promised you to make for you a book out of my own 
brains, and that I shall try to do, avoiding useless citations. It 
would be far easier to take my scissors and cut these letters, 
paragraph by paragraph, out of the volumes in my library. I hope 
you will not be inclined to say it would be better had I done so, 
as the letters would have been better letters. There, however, 
are the volumes; too many of which, like all the early literature 
of our calling, have been made by the scissors, being the lazy 
repetitions of what has been said a thousand times. I hope, though, 
you will take every opportunity of reading what those books con- 
tain on all these topics. There is no danger of your reading too 
much. The more you read, the better will you be prepared to 
judge, whether what I say here and in the lecture room, be just 
and reasonable or not. Farewell. C. D. M. 



190 RETROVERSION. 



LETTER XVI. 

RETROVERSIO UTERI. 

Gentlemen :— My purpose as to this letter, is to put down in 
it the opinions I have formed, as to a very common malady, which, 
though it has been the subject of frequent publications, and of 
much discussion, seems to me not to have been placed in that 
clear open light, that the simplicity of its causes, ought to have 
enabled authors to shed upon it, in their printed communications. 

Retroversion of the womb, or the state wherein the womb is 
turned over backwards, is one of the most common of the devia- 
tions of the organ met w T ith in practice : it appears to rne to be a 
case whose principles, as well as the methods of cure, ought to be 
easily understood ; yet I have been much surprised to find many 
women come to this city from remote districts and states, in order 
to.be treated for some uterine disorder, which had never been 
fully investigated by their physicians at home ; cases of which the 
outward signs were in general, sufficiently clear to warrant one, if 
not to pronounce this diagnosis, yet at least sufficiently to point 
out the necessity of completing this diagnosis by touching. 

Before we proceed farther, let me beg you to stop for a moment, 
in order to reflect upon the situation of the womb within the pelvis, 
and its relations and connections with the various parts by which 
it is environed ; to regard it as placed betwixt the bladder and 
the rectum, being largely attached to the bladder at the utero- 
vesical, and vesico-vaginal septum ; to the vagina, upon whose 
top it is invaginated, and subject, therefore, to be alternately moved 
backwards towards the sacrum, or forwards towards the pubes, 
by the varying conditions of the bladder of urine, as filled or 
empty. 

Whenever the urine is evacuated, the bladder is collapsed, or 
rather contracted; and the womb is brought nearer the pelvis, — 
when the bladder is full, it pushes the womb towards the sacrum. 
What is the limit of this retreat of the womb ? Is there no appa- 
ratus to prevent it from being carried beyond due measure back- 



RETROVERSION. 191 

wards? — oris it liable to be pushed bodily against the face of the 
os sacrum? 

What other office could you assign to the ligamenta rotunda 
than that of preventing the womb from going too far in a backward 
direction? Be assured that the sole use, destiny, or office of the 
round ligaments, is to oppose the retreat of the uterus beyond due 
measure backwards; and that, like the forestay of a ship's mast, 
each ligament is charged with the duty of retaining the organ in 
sufficient propinquity to the anterior semi-circumference of the 
pelvis, and of retaining it erect nearly in the middle, not too far 
back, and not too nigh the pelvis, where its presence might interfere 
with the office of the bladder of urine. 

Suppose a woman could, by any accident, or by any surgical 
operation, have her round ligaments cut off! You perceive the 
inevitable consequence would be, that the womb would turn over 
backwards, and rest against the sacrum • or even dive backwards, 
carrying its head deep down into the peritoneal cul-de-sac be- 
twixt the vagina and the rectum, while its os uteri would point 
upwards towards the bladder, behind and above the crown of the 
pubal arch. This would be a true retroversion ; but if, by any 
art, the cut ends of the round ligaments could be made to unite 
again, the retroversion would be at once cured ; for there can be 
no retroversion with round ligaments only two and a half inches 
long. How could there be? — since the plane of the superior 
strait is four and a half inches over, from front to rear. Certainly, 
two and a half inches of round ligament cannot stretch across 
the plane, which is four and a half inches long. 

Retroversion of the womb, then, is a case in which the fault, 
the maladive or pathological fault, is in the round ligaments ; and 
not in the womb itself. Hence, if you intend to cure a woman 
of retroversion, your intention should have reference, rather to the 
ligamenta rotunda, than to the womb. Cut off the round liga- 
ments, and you will have retroversion ; heal the wound, and the 
ligament being united again at the wounded point, the womb will 
be held up, and there can be no retroversion. Relax, stretch, 
elongate the ligamenta rotunda, and the womb retroverts ; — 
strengthen, shorten, cease to elongate the same ligaments, and 
the patient is cured. This is the doctrine. 

As to the persons subject to this accident, it must be admitted 
that the virgin and the wife, the sterile and the child-bearing are 



192 RETROVERSION. 

all liable to it, because they are all liable to the operation of causes 
that over-strain, and elongate the round ligaments. 

Yet doubtless it is of more frequent occurrence in child-bearers 
than in other women ; since such are the persons in whom the 
round ligaments are most frequently put on the stretch, elon- 
gated, and weakened. Nevertheless, it is true that a great many 
women, who have never conceived, are troubled with the affection. 
I speak very confidently as to the liability of the virgin to the dis- 
order, since I have treated it in such persons. 

I said that the malady is essentially a malady of the round 
ligaments, though the womb be the apparently suffering organ. 
I do not mean to say to you, that it is a matter of little moment 
that the womb should be reversed, and that the matter of great 
moment has relation to the round ligaments only ; fori am not 
so inaccessible to reason and observation, as not to know, and 
admit, that a distorted, and so to speak, dislocated condition of 
the uterus, particularly in pregnancy, is a matter of serious 
moment; nay, a state of imminent danger, and of great pain. In 
all such cases you should make haste to relieve the womb from its 
false and dangerous position — remembering, though, all the while, 
that it is not the fault of the womb, but of the round ligament; — 
that your intention should be to disembarrass the womb, by taking 
it out of the false position, in which it has fallen, not through any 
fault or disease of its own, but through fault and disease of the 
round ligament, which ought to have sustained and maintained it 
in its true normal attitude, but did not. 

Let me repeat, that a healthy round ligament will not reach 
across the plane of the pelvis from front to rear — but a weakened, 
or relaxed, or overstretched one may be so very long, that it may 
reach not only across the whole plane, but even down almost to 
the point of the coccyx. And now, I think I have defined my 
opinion, and that we cannot misunderstand each other in the 
sequel. 

Here is a drawing copied from the specimen that I showed you 
last winter; and which represents it very correctly. The figure is a 
half female-pelvis, with its contents, but exhibiting the womb retro- 
verted. Look how the posterior face of the womb has become, 
by the retroversion, the anterior surface; and see how the os 
uteri is directed upwards, instead of downwards. This womb is 
quite topsy-turvy. The fundus of the womb impresses itself into 



RETROVERSION. 



193 



the texture of the rectum ; and the bladder of urine is distorted 
by the dislocation of its neighboring organ. 

The artist has made 
a dotted line ending 
at (b), "which shows 
you how much the 
round ligament must 
have been stretched, to 
let it reach thus to the 
bottom of the pelvis. 
The other dotted line, 
marked (a), shows 
how long, and wdiere, 
the unstretched round 
ligament ought to be, 
and was, before the re- 
troversion took place. 
If you push the index 
into the vagina, you 
will press it on the 
fundus and corpus ute- 
ri, down near to the 
sacrum, while the os 
is high up near the 
pubis. I think the 
drawing may explain the state of the case better than all the 
balance of this sheet. 

In looking through the books again to find what the writers 
think on this subject, which, as you may remember, I have often 
presented in this light at our meetings in the lecture-room, I 
discover them not to be so clear and concise in their apprehen- 
sions of the true nature of the case, as I think you will be, if you 
adopt the opinions above expressed and set forth. They all know 
that retroversion is retroversion — but they seem not to know why. 
The famous Dr. Deleurye, in his Tralte des Accouche mens, Par. 
127, says of the round ligaments, " Hors le temps de la grossesse, 
les ligamens ne sont d'aucun usage a la matrice; pendant la 
grossesse, ils peuvent lui servir, etant tendus et droits." So that 
Mons. Deleurye appears to regard them as provisions against a 
13 




194 RETROVERSION. 

gestative want. Most of the authors, I believe, equally overlook 
the ligaments, as allowing by their failure the occurrence of a 
retroversion, except Velpeau, who, at p. 94, 2d edition, Paris, 
1835, says, "but for them the womb would every moment be 
turned over backwards by the bladder, which is distended several 
times every day, with urine." They have escaped the attention 
of Robt. Lee, whom nothing escapes. Cazeaux passes them by 
with scarcely a remark; nor does Churchill seem to deem them 
worthy of notice. Even MM. Desormeau and Paul Dubois, 
authors of the article in the Nouveau Diet, de Medecine, pass over 
these organs without due regard, while Dr. Jacquemier's new 
Manual of Midwifery, which is the last novelty in our line, seems 
also to attribute this pathological condition to any tissue save the 
one really in fault. Authors say it is a full bladder that causes 
retroversion, or that retroversion causes the bladder to be over- 
filled. 

For example, — here is a brochure entitled Memoire sur la Re- 
troversion de la Matrice dans Petal de la Grossesse, 16 pages, 
8vo., 1843, by the distinguished Dr. Amussat, of Paris. I shall 
translate a whole paragraph from p. 22. It is in the following 
words: "A retention of the urine has been indicated as one of the 
causes of retroversion of the womb. In my opinion the effect has 
been mistaken for the cause; a retention of urine being an inevi- 
table consequence of the displacement; since the cervix, provided 
it have not been really bent, must immediately press upon the 
urethra and obstruct the escape of the urine. Certainly where 
the retention of urine produced in this way is misunderstood, the 
distention of the bladder will tend to increase the displacement, 
and the use of the catheter, by drawing off the urine, might partly 
cause the organ to rise again above the promontory of the sacrum. 
But, it is incorrect to say that a retention of urine may produce a 
retroversion of the womb ; it can only increase it — perpetuate it. 
However, I admit that where the bladder is habitually distended 
by a great quantity of water, and where this distention is a conse- 
quence of disease of the bladder or the urethra, there might in the 
long run follow a depression of the fundus from the weight of the 
bladder, and so, a tendency to a retroversion." 

There, what say you as to Dr. Amussat's view of the case ? In 
his whole pamphlet there is not one word of the round ligaments — 



RETROVERSION. 195 

and a man who teaches you the doctrines of retroversion without 
mentioning them, is like a surgeon who should teach you the whole 
doctrine of dislocation of the hip-joint without the least allusion to 
the orbicular ligament or the capsule. You might ask such a 
teacher, can a hip-joint be dislocated without troubling the orbicu- 
lar and capsular ligaments ? — and you might ask M. Amussat if 
he thinks a womb could be retroverted with a pair of ligamenta 
rotunda not over two inches and a half long! 

Dr. Samuel Merriman's " Dissertation on Retroversion of the 
Womb, including some Observations on Extra-uterine Gestation" 
is equally devoid of concision in the exposition of the causes of 
the accident, for his whole book from beginning to end has not 
one word on the subject of the ligaments. 

Dr. John Burns, of Glasgow, whose work, with notes by the 
late Professor James, was so long a text-book of the University of 
Pennsylvania, has not an item on the subject of the round liga- 
ments in the whole of his article, which you will find in vol. i. p. 
186, of Burns'* Midwifery. Dr. Robert Lee, of London, who in 
my opinion is one of the ablest men in his department now alive, 
does not hint at the existence of ligamenta rotunda in his article 
on retroversion, which is at page 207 of his " Lectures on the 
Theory and Practice of Midwifery, delivered in the Theatre of 
St. George's Hospital. London, 1842, 8vo." Nor does Dr. 
William Hunter, the father of all retroversion authors, say any- 
thing about them. 

I think, that as retroversion is an accident very common, and 
in pregnancy, very dangerous, it is important that you should not 
only be well aware of the state of the womb under it, but of the 
implications it may introduce as to other tissues ; and it is exi- 
gent, not only to know these things, but why they do happen, so 
as to enable you to direct aright your intentions and method of 
cure. 

Can you entertain any scruples in regard to my explanation of 
it ? Let us try conclusions then. 

The bladder, when it fills from the perpetual stillicidium of the 
two ureters, always fills first in a direction backwards, towards the 
sacrum; and when it cannot distend any farther, in that direction, 
its fundus mounts upwards towards the umbilicus. In Dr. Hun- 
ter's case, figured in his anatomical tables of the gravid womb, it 



196 RETROVERSION. 

went up halfway between the navel and pit of the stomach. Now, 
in a healthy strong woman, the bladder, in filling, cannot go back 
to the sacrum, pushing the womb before it, because, as soon as 
the round ligaments are put on the stretch, they cease to yield, 
and compel the bladder to develop its walls in an upward direc- 
tion towards the navel. The womb is therefore safe ; it repels the 
intrusion of the bladder, and makes it rise upward, in the belly, 
agreeably to the explanation of M. Velpeau, in his Midwifery. 
But, there are certain women, who, from insensibility of their ner- 
vous system, or from their situation in the world, habitually allow 
the bladder to become enormously distended, before they yield to 
the urgent call of nature. Such a habit must, inevitably, gene- 
rate a laxity of the round ligaments, which being daily over- 
strained, yield more and more to the antagonizing force of the 
distended bladder, until they end, by becoming too long to hold 
the womb in due propinquity to the pubis; wherefore, it must fall 
backwards to the sacrum, since there is nothing devised for holding 
it forward, except these round ligaments, that can now no longer 
do their office. This slow, gradual elongation of the round liga- 
ments, will explain to you the reasonableness of those writers 
who say, that retroversion may, in some women, come on gradu- 
ally, and by small degrees, until it is at length completed. I have 
myself, no doubt, that the cases of retroversion in the unmarried, 
are mostly brought on in this slow chronical way ; though, it is 
true, when the woman is prepared for it by this process, some 
sudden exertion or succussion of the body, may complete it in an 
instant. Suppose the round ligaments to have become habitually 
overstretched, until they have become four and one-fourth inches 
long. Do you not perceive, that a full bladder, suddenly jammed 
downwards in a fit of vomiting, or coughing, or straining, or jump- 
ing, might press the head of the womb down beneath the sacro- 
vertebral angle, whence it would not be likely soon to be pulled 
up again by the said ligaments. 

Any pressure upon the rectum, whether from within, or without 
the cavity of the gut ; any inflammation of it, or any irritation act- 
ing upon it or the bladder, excites what is called tenesmus or 
a bearing-down. In tenesmus, all the parts contained within the 
pelvis, are pushed downwards towards the perineal strait, and, as 
the tenesmic feeling becomes more and more intense, it must hap- 



RETROVERSION. 197 

pen that the overturned organ shall be pushed down into the peri- 
toneal cul-de-sac, betwixt the bowel and the vagina. The womb 
cannot come into this situation, without greatly augmenting the 
tenesmic feeling, and bringing on other complaints, such as stran- 
gury, or dysury, urinary tenesmus, rectal tenesmus, pain in the 
middle of the sacrum, in the ligamenta rotunda, sciatic pains, and 
pains along the distributive places of the obturator nerves in the 
groins and thighs, and a great disturbance of the entire splanchnic 
system of innervations. 

You may very readily conceive, of the disturbing influences, as 
to the general health, bodily and mental, of such a state of things ; 
and in making up your notions of the modality of such disturbing 
operations, you will not leave out of the computation, that vast 
and dominant force, which the reproductive organs of the female 
ever exert upon her entire physical nature. How much greater 
that force when the womb and the ovaries, and the whole repro- 
ductive apparatus, indeed, is advanced in power by the sanguine 
affluctions, and nervous determinations to which they are subject 
under such circumstances. You should not be surprised to witness 
the wildest hysterical phenomena; nor, indeed, the whole protean 
genus of hysteria. 

I have been accustomed to observe these influences for many 
years past, and have seen them carried to the extent of producing 
a temporary insanity and the various modifications of the nervous 
manifestation below that which constitutes insanity. 

The disordered womb can, by its nervous connections with the 
spinal and sympathetic nerves, disturb and vex any and every 
organ in the body, from the brain to the massa carnea on the sole 
of the foot. It can vex the pharynx and oesophagus with spasm 
or globus — close the jaws through the masseters or temporals, 
jaundice the blood by its influence on the liver, cause ischuria or 
diabetes in a moment, bring on constipation or diarrhoea, simulate 
apoplexy and eclampsia, set the hemispheres in a rage of in- 
sanity, or excite the cerebellum to the manifesting of chorea, or 
abolish the sensorial and motor chords of the spinal marrow; but, 
if, in the non-gravid condition, the retroverted deviation of the 
uterus can cause such great derangements, what must be those 
that attend some of the terrible consequences of retroversion of the 
gravid womb. They are truly appalling. They consist in all the 



1 98 RETROVERSION . 

fruits of complete compression and obstruction of the contents of 
the pelvis, by the growing womb. Dr. Wm. Hunter describes a 
case, the first one perhaps, which was clearly understood, wherein, 
after the death of the patient, it was found that the womb had 
continued to expand under the development forces of the ovum, 
until it so completely jammed and impacted the uterus into every 
anfractuosity of the pelvis — arresting the flow of the urine, and 
the course of the rectum — that the uterine mass could not be ex- 
tracted through the superior strait, until the ossa pubis were sepa- 
rated by the saw. 

This case of Dr. Hunter's was under the care of Dr. Walter 
Wall, who had studied in Paris, where he had received the in- 
struction of Gregoire. Persevering attempts were made to restore 
the womb to its natural position ; but the magnitude of the ovum, at 
four months, rendered it impossible to get the fundus above the 
linea ileo-pectinea. The bladder was filled, so that its fundus was 
half way between the umbilicus and the scrobiculus cordis, and 
she died shortly after Dr. Hunter saw her. Dr. Hunter gives 
very beautiful drawings of the specimen, in his great Tables of 
the gravid uterus. Before the examination of the body, he in- 
vited many physicians to be present, and gave a lecture on the 
subject. It was Dr. Hunter who applied the name of retroversion, 
which is now adopted universally. Many physicians had seen 
the malady before his time, but I think him entitled to the credit 
of describing it, and making it first clearly understood. 

As to the several signs by which the accident may be made 
known, they are pain and obstruction or irritation within the pel- 
vis. You rejoin, perhaps, that other affections are manifested by 
the same symptoms; and it is very true that simple prolapsion 
gives pain in the pelvis, and in the back; and troubles the course 
of the urine, &c. ; — but, in forming your inference as to the ex- 
istence of a retroversion, upon representations of pain made by 
the patient, you will address your inquiries in such a manner, as 
to deduce from the history of the attack, a judgment as to its seat, 
causes and nature. 

For example. I was called some time since to a young woman 
residing in Ninth street. 

When I presented myself to her, I found her lying upon the 
bed, apparently in pain. It was afternoon. 



RETROVERSION. 199 

" Will you please inform me what it is that has induced you to 
call for me, madam?" 

"I am in great pain, sir." 

" Where is the pain situated ?" 

"In the lower part of the stomach and back." 

" You mean in the lower part of the abdomen, I presume; near 
the shear-bone, or bar-bone." 

" Yes, sir." 

" How long have you suffered from it ?" 

" Since the early morning." 

" Are you married?" 

" Yes, sir, these six weeks." 

" What brought the pain on you?" 

" I do not know, sir. It came on in the car, as I was return- 
ing from New York." 

" Have you any difficulty in making water?" 

" I cannot make a drop ; or at least, only a few drops pass, 
with the most violent efforts — and the urgency never ceases; I am 
suffering dreadfully, indeed." 

"Had you ever such an attack before?" 

" Never." 

" What's your age ?" 

"Twenty-two, sir." 

" Are you regular?" 

"No, sir." 

"Do you suppose you are enceinte?" 

"Yes, sir." 

"How long?" 

"About five weeks." 

" And you never felt this disorder before?" 

" I never felt anything of the sort till to-day." 

" Have you pain in the back, did you say, too?" 

"Yes, dreadful." 

" Is that pain chiefly felt about three inches above the lower 
end of the back bone?" 

"Exactly there." 

"You have a retroverted womb, madam; with retention of 
urine, caused by it." 

"I do not know what you mean, sir." 



200 RETROVERSION. 

" I mean that, as you are pregnant some five weeks, the womb 
is become much larger than it was before you were married ; and 
it is now turned over backwards ; — in fact, it is topsy-turvy. The 
pressure of the top of your womb against the lower part of the 
bowel and the back bone, gives you pain in that situation ; while 
the bottom, or rather the point of the womb, is pressed with force 
against the bladder of urine, vexing and paining it, and stopping 
the course of the water, which can only escape drop by drop, 
while your bladder becomes continually fuller and fuller. It is 
very full now." 

"Why, what in the world is to be done?" 

" You are to allow me to remedy the difficulty." 

"How?" 

"By replacing the womb in its natural position." 

" But how can you do that ?" 

"With my hand." 

" I can't think of such a thing." 

"Very well, madam, I shall have to bid you a good afternoon, 
for I can't think of anything else. In fact, there's nothing else to 
be done for you." 

"Why, I'd rather die." 

" As you please, madam; you are the mistress; ce que femme 
veut, Dieu le veut ; but I hope you will permit me to say it would 
be very silly of you to die, for want of the power to make water, 
when there's a physician at hand, can put you so easily in the way 
to do it easily." 

And she resorted to the ladies' resort — tears. After she had 
comforted herself a little in this way, and had come to her calmer 
reason again — 

"Will it hurt me, sir?" 

"Oh no, not a bit." 

" What am I to do, then, if I must ?" 

" You are to lie on your left side, in bed. Covered up head 
and ears, with the bed-clothes. You are to draw up your knees 
very high, and I will cure you in a moment." 

I washed my hands ; I always do that first. I dipped the index 
finger of the right hand in oil. With its point I felt the gravid 
bas-fond of the womb looking downwards and forwards in the 
pelvis, while the os tineas was cocked up against the urethra above 
the arch. Look again at the wood-cut. 



RETROVERSION. 201 

" Don't bear down now, child ! don't resist the pressure of my 
hand! I shall not hurt you at all, not in the least !" and so by a 
gentle, steady, augmented pressure against the bas-fond, press- 
ing it upwards and backwards, I followed the ascending fundus 
until it suddenly escaped above the promontory, upon which the 
os uteri looked downwards again, and the organ was reposited." 

" Now, how do you feel ?" 

" Oh, greatly relieved." 

" Set up, and try to make water. I shall retire from your cham- 
ber. Call me when you are done. Is there a wash-stand in the 
next chamber?" 

In a few minutes she called me back ; thankfully telling me 
she had made a large quantity of water, and was quite well again. 

" Is not this, bad as it is, better than dying?" 

" Oh yes, sir, thank you!" 

" I think it is. Farewell, madam. Let me tell you though, 
before I go, that if you had made water freely, before you started 
from New York this morning, you would not have had your womb 
turned over, for nothing did it but the bladder. Your bladder was 
full when you got up in the morning; you was hurried to the 
steamer, and it became fuller, because you could not relieve your- 
self in company. There was not room enough left for both the 
bladder, and the womb in their usual places. So the bladder 
thrust the womb downwards and backwards, until it was over- 
set. The round ligaments could not hold it up, they had to give 
way. See here, I have made a drawing of the situation of things. 
This is the womb overturned backwards. These are the round 
ligaments, stretched almost to breaking. That's the mouth of the 
womb turned up here, and compressing this neck of the bladder, 
which you see is horribly distended with water, that gave you so 
much pain. As soon as I pushed the womb up to this point, the 
mouth of it turned down to this place, its natural situation, and 
the pressure being taken off from the neck of the bladder, you 
could easily make water. Do you understand it now ?" 

" Oh yes, perfectly." 

" Take care then, not to let it get so full again, or it will serve 
you the same trick a second time." 

"Yes, sir." 

" Farewell, madam." 



202 RETROVERSION. 

" Good-bye, sir." 

I have given you the foregoing dialogue, as an example of many 
conversations I have held on such subjects, with the sufferers from 
an accident. 

What inference, other than that I did draw, could I possibly 
deduce from her relation ? Think over, for a moment, the ana- 
tomy of the parts within the pelvis, and you will see that I could 
not well obtain any other inference than that of an overset of the 
uterus. 

If the patient had replied to my questions, that she had long 
suffered with backache, and dysury, &c, I might have supposed 
some other cause than retroverted gravid womb; but as she was 
young and strong, how could I imagine that anything else could 
have happened to her pregnant uterus, except that which had 
really happened to it. There was nothing else to be deemed of 
it, and so I could confidently say to her — your womb is retro- 
verted. 

You will not expect always to relieve the patient so promptly, 
nor will your diagnostic always be so correct. This at least, I 
have many times found to be the case, as to my own patients ; for 
I have very confidently expected to find retroversion, where there 
was only prolapsus: and sometimes, where a true anteversion of 
the organ existed. There are other cases, again, in which the 
splanchnic neuralgia that I described in Letter XII. p. 131, has 
depended upon retroversion, while I expected to discover a simple 
uterine descent. For the most part, however, you may venture 
to speak with boldness, upon a clear history of a sudden case, in 
a healthy pregnant woman. You may also entertain a very con- 
fident reliance in the diagnosis, even in the chronic forms, but, a 
fortiori, in the instances of the accident connected with preg- 
nancy. 

If you should have reason to speak very confidently on the diag- 
nosis, from this mere external or rational evidence, you would of 
course verify the opinion by the touch, should you continue in 
charge of the case. The touch should be effected in the usual 
way ; the woman being on her left side, in a flexed position. In 
retroversion, the os uteri is behind the symphysis, looking more 
or less obliquely upwards, according as the fundus is more or less 
completely forced behind the vagina, while the os tincse is found 



CASE OF RETROVERSION. 203 

up near the symphysis. The fundus is felt in the non-gravid, as a 
firm, solid, hemispherical mass, lying against the exterior surface 
of the posterior wall of the vagina, which is pushed more or less 
near to the os externum, according to the degree of the overset. 
In M. Mayer's case, it was pushed through that wall, which it 
ruptured, and turning quite upside down, came out through the 
vulva. 

It is true you might commit an error in the diagnosis — mistak- 
ing some tumor formed in, or fallen into the pelvic cul-de-sac of 
peritoneum, for the overturned fundus ; but I apprehend but little 
likelihood of such a mistake, should you trace the cervix from the 
os uteri to the corpus; and so to the fundus of the organ; the 
more particularly, as in all cases not perfectly clear, you would 
resort to the exploration by the rectum. 

I said you will not always be able to relieve the patient so rea- 
dily. 

A lady called upon me many years ago, on account of a 
retention of urine. I found her pregnant at more than three 
months, and the bladder making a large painful tumor in the hy- 
pogastrium. When I informed her of the probable cause of her 
distress, she very readily accepted my offer to attempt to relieve 
her of the difficulty. 

As the uterus at three months is already very large, I did not 
make any attempt to reposit the womb, while the bladder was still 
filled with a great quantity of water; for, when the bladder is so dis- 
tended, I presume it will effectually prevent success in any attempt 
at reposition, particularly, the womb itself being also very full. If 
the rectum be overloaded, that part of the gut that lies above the 
overset uterus, will be so distended with feces, as to aid very mate- 
rially in keeping the uterus down. The bowel should be tho- 
roughly emptied by an enema of salt and water, before anything 
else is done. In the case now under consideration, it was not 
necessary to resort to this aid. Instead, therefore, of uselessly 
worrying my patient, I commenced, by drawing off the water 
with a catheter : — and I found it necessary to carry the female 
catheter almost up to the ring, before I could introduce the point 
into the cavity of the bladder ; so much was the urethra stretched 
by the complete see-saw of the womb. By way of parenthesis, 
I must here warn you that, in these distortions of the organs, you 
may find yourself disappointed in attempts to draw the urine by 



204 CASE OF RETROVERSION. 

a female sound, owing to the great lengthening of the canal; in 
any such case, you would have no difficulty in reaching the de- 
posit, should you employ a male catheter. I mean a French one. 

When I had evacuated the bladder, I proceeded to attempt the 
reposition of the organ ; but I found, on thrusting against it with 
two fingers of the right hand, I could not make it ascend, — but 
that my fingers indented the womb so much, as to expose me to 
the risk of disturbing the connection of the ovum to the uterine 
walls, and so causing an abortion to take place. This reflection 
induced me to pause. 

Here, said I, is a woman pregnant at three months, past ; who 
has suddenly suffered a retroversion, probably brought on by a dis- 
tended bladder; which, pushing the womb backwards and down- 
wards, has, upon some sudden succession, shock, or straining by 
the abdominal muscles, thrust the fundus fairly down below the 
promontory of the sacrum, which holds it there. But now, that I 
have removed the pressure from the bladder, by emptying it ; if I 
persist in attempts to push the womb up again, I shall perhaps 
break or detach the membranes, or possibly separate a part of the 
placenta. I shall, therefore, do no such thing; I shall hope and 
trust, that the round ligaments have strength enough to pull the 
womb up from out of its new bed, and set it on end again — the 
more likely, as I have no reason to suppose they are chronically 
weakened and elongated. Many samples have been met with of 
the womb restored by taking off the pressure of the bladder. Dr. 
Ingleby, in his Obstetric Medicine, p. 65, describes a case in 
which the "womb rectified its position almost instantly after the 
bladder was emptied." He relates a good success, also, at p. 67, 
in which the womb remained retroverted at the fourth month of 
pregnancy, notwithstanding the daily introduction of the catheter 
for many days; Dr. Ingleby advised that it should be introduced 
every four hours. In this instance, notwithstanding the fundus 
was almost down to the anus, and the os uteri was just above the 
brim — on the third day of repeating the catheterism every four 
hours, it was restored to its natural position. I therefore explained 
to the patient the views which led me to desist from troubling her 
for the present, and promised to observe the case. 

Upon calling many hours afterwards, she had made no water; 
the bladder was again to be felt, full, above the symphysis pubis, 
whereupon I used the catheter again; and then renewed my 



TREATMENT OF RETROVERSION. 205 

attempts to get the womb up, in vain. The attempt to press the 
organ upwards, was resisted by two causes; 1st, the fixed state 
of the mass extending quite across the pelvis, and, 2d, the bear- 
ing-down, or tenesmic effort, which was excited by the pressure 
of the fingers. 

A person who is on the knees, with the top of the sternum rest- 
ing on the same plane as the knees, cannot bear down. The 
tenesmic power is either wholly annulled, or so weakened, that it 
is nearly nullified by that attitude. Dr. Hunter's patient was 
placed in this position, but she was too far gone to enable him to 
succeed. 

I directed my patient to turn on her face in bed; — then to 
draw her knees upwards, until the thighs should be vertical; and 
to keep the top of her breast upon the matrass, so as to have the 
pelvis elevated to the highest point. 

Introducing two fingers into the vagina, and conducting them 
along the curve of the sacrum, I found I could disengage the 
womb from its jammed position; and following it as it moved, 
I had the pleasure to find it escaping towards the plane of the 
superior strait, while the os tincse see-sawed down into its proper 
place in the vagina; and she was relieved. Her retention of urine 
returned no more ; and I attended her at the birth of the child, at 
term. 

It is worthy of remark, that two years later, I had to repeat the 
same process for the same lady, in a succeeding pregnancy, and 
with equally fortunate results. Dr. Amussat, in his work on 
retroversion, describes a similar case, in which the accident oc - 
curred in two successive pregnancies. 

In neither of these cases did I resort to venesection, which Dr. 
Dewees justly commends as a most important item in the treatment 
of the rebellious cases. 

Our celebrated countryman was a bold bleeder, and was ac- 
customed to overcome all obstacles of soft resistance, by copious 
abstractions of blood. I have heard him highly recommend the 
lancet, as a means of subduing the tenesmic resistance that is 
awakened by the hand of the surgeon, disturbing the tumor. 
But having found the position above recommended, amply pow- 
erful for the subduction of the tenesmic force, I with confidence 
recommend it to you, as preferable to large abstractions of blood ; 



206 CHRONIC RETROVERSION. 

which are not indifferent in their prospective influence upon the 
health. 

Should you, however, in any such case, have reason to suppose 
that the engorgement and irritation are about passing, or already 
passed into the stage of inflammatory action, I trust you would not 
hesitate to resort in the freest manner, to the curative and conserv- 
ative efficiency of venesection. 

I hope you will see, my young friends, that in taking the above 
method of laying before you my views upon retroversion, I supposed 
that a concise account of the symptoms, state, and cure of some 
cases would be more efficacious to clear the matter in your minds 
than the longest didactic and stately detail. These cases might 
perhaps suffice for the end I have in view, since ex uno disce omnes 
is nearly true. Yet I shall beg to say that, you will probably 
meet with some specimens of the accident that you cannot remedy 
by any means, and that it would be very dangerous to persist in 
curing them. Let me speak of them, therefore. 

The chronic duration of a retroversion of the womb can scarcely 
be regarded as consistent with a healthful state of that organ. 
The distortion, the pressure, the firm and continued contact of 
parts not designed in nature to be brought into fixed apposition, 
develop an adhesive inflammation, and such inflammation is at 
an end when it has finished its mission of uniting two parts into 
one, by a bond of union common to both. Doubtless, many are 
the cases of retroversion that are thus rendered incurable, and 
these are the samples against which you should be warned, lest 
in your zealous attempts to succeed in restoring the womb to its 
normal attitude, you should effect some disruption of tissues, the 
laceration or even the tension of which might endanger the life of 
the patient. Hamlet is very right where, in his soliloquy, he 
resolves it is 

" Better to bear the ills we have, 
Than fly to others that we know not of." 

I speak very confidently as to the confinement of the fundus in 
the back part of the pelvis by adhesions, not from any opportunity 
I have had of proving the fact by a necroscopic test, but by the 
circumstances of a case that came under my charge six or seven 
years since. It was that of a married lady from one of the West- 
ern States. In this case all the usual phenomena of the malady 
were present. The os uteri was directed strongly towards the 



RETROVERSION. 207 

symphysis pubis, and the rounded fundus of the womb was clearly 
distinguishable on examination, both by the vagina and the rec- 
tum. During several consecutive months, I made various attempts 
with the hand, in both ways, to push the fundus upwards ; and I 
also introduced a large globe-pessary, in the hope, that, by its 
protracted pressure in an upward direction, it might gradually 
loosen the ancient attachments of the womb, and thus allow it to 
recover. I did not succeed to any great extent in repositing the 
deviated organ ; but the patient left this quarter of the country in 
improved health, and with the organ less impacted and less im- 
movable than when I took charge of the case. I concluded it to 
be not possible to disengage it wholly from the ties by which it 
was bound down. 

Amussat, Mem. sur la Retroversion, &c, p. 27, says, " I have 
two drawings representing cases of retroversion of the non-gravid 
womb ; in one of them the subject was an adult, and there was 
adhesion to the rectum ; the other case was that of a new-born 
child; and at page 29 he continues thus: 

" The consequences of reposition of the retroverted womb are 
far from being so simple and fortunate, as might be supposed, to 
judge from the three cases under my care. Indeed, in some in- 
stances the manoeuvres, even careful ones performed with the 
fingers introduced into the vagina, have brought on abortion, and 
in some cases this accident itself has been followed by fatal 
metro-peritonitis. 

"If a female have been the subject of a puerperal or other 
peritonitis, she may have recovered with adhesions of the womb 
to the peritoneum behind it. Such a state would not necessarily 
vitiate her power to conceive. She might even develop the child 
in a uterus partially retained by adhesive connection within the 
pelvis, but would be more likely to miscarry as soon as the trac- 
tions should become intolerable to the uterus. We have examples 
of adherent uterus causing death by hemorrhages." 

I pray you allow me, at the risk of iteration, to call your atten- 
tion to the remarks I made in a former letter, p. 129, as to the 
mode in which the womb changes its position in all the prolap- 
sions. I said the womb falls down along a curved line — Cams' 
curve — and that, when the os tinca3 presents itself at the os mag- 
num, the uterus is lying in a horizontal position across the pelvis. 
If you do not keep this fact in mind, you will be very apt to 



208 RETROVERSION. 

mistake a simple prolapsus uteri for a retroversion of the organ — 
but the cases are very different. In retroversion always expect 
to find the os uteri above the crown of the pubal arch, and not 
beneath it. If I am correct in this view, I differ from M. Colom- 
bat, who seems to approve of the opinion stated in the following 
sentence from page 154 of his work. " The terms anteversion 
and retroversion have been applied to those cases in which the 
longitudinal axis of the uterus has been found placed in a hori- 
zontal position." If M. Colombat, who is generally a very relia- 
ble authority, is right in these words, then there can be no differ- 
ence between retroversion and prolapsus — since in each case, the 
womb is horizontal in the pelvis. According to my view, you 
shall always insist in retroversion, on finding the vaginal cervix 
higher than the crown of the pubic arch — for where it is at a lower 
level than that, the case can claim to be only a true prolapsus. I 
am quite confident that many mistakes are made as to this diag- 
nosis. 

Such mistakes are the more easily made, where what is called im- 
mobility of the womb exists ; a case in which the organ refuses to 
retreat upwards in the pelvis, for any allowable degree of pressure, 
except the slow pressure of a pessary ; which I have proved capa- 
ble in the course of twenty-four to forty-eight hours, to lift quite 
high up in the pelvis, a womb that I could not venture to start 
in that direction, by any short-lived pressure I could make with 
the index and medius. 

I have not made any remarks as to the manner in which preg- 
nancy operates to produce the disorder in question. I am not at 
all inclined to admit the theory, that the womb goes over back- 
wards, because the posterior half of the organ yields to the growing 
ovum, faster than the anterior half. I have explained how a full 
bladder may cause the slow gradual occurrence of our disease. 
But it is more frequently seen to arise in married than in single 
women; why is this the case? 

You should reflect that the round ligament is from two and a 
half to three inches long, and that arising from the angle of the 
womb, it runs to be inserted on the tissues exterior to the os pubis. 
The non-gravid womb is two to two and a half inches long, from 
top to bottom; when a woman becomes enceinte, the growing 
ovum compels, by its antagonistic expansion, the uterus to expand, 
in order to yield and furnish the admirable nidus of the ovum. 



PREGNANCY AS CAUSE OF RETROVERSION. 209 

The process of expansion continues for nine months, at the end 
of which time, the summit of the womb is at the scrobiculus cordis, 
and distant some twelve inches from its os tinea?. During the 
whole of this growing state, the ligamenta rotunda continue to 
exercise their office of forestay of the womb, holding it, or assist- 
ing to hold it forward. But, by the end of the pregnancy, your 
three inches of round ligament have become five or six, or more 
inches in length. Now comes the labor, which, in some women, 
requires half an hour only to complete it, and the average of all 
labors is but four hours. The womb in two or four hours goes 
down, far towards the plane of the superior strait, and continues 
to condense its tissue, so that in twenty days, it is not larger than 
the non-gravid womb. But if the round ligaments do not con- 
dense themselves equably with the uterus itself, what guaranty 
have we, that the womb shall not tumble over backwards, as soon 
as it has become small enough to allow its fundus to subside 
below the promontory ; seeing especially that its round ligaments 
are left relaxed, elongated, stretched, and offering no opposition 
to the fall. 

You should take into consideration, that though the round liga- 
ments spring from the uterus, and are uterine in textural nature or 
at least partially so, and therefore muscular, they have not power 
of contraction so active and quick as those appertaining to the 
w T omb proper, and then you will recognize the cause of those fre- 
quently observed retroversions, that occur in women, pale, thin, 
watery and relaxed, who, offering no considerable resistance to the 
escape of the child, are delivered in a pain or two, before the 
doctor can come. 

I do not like to see a woman delivered of her child too easily, 
for it indicates a feeble resistance, and is more frequently followed 
by disorders, especially such as that under consideration, than 
where a solid and stern resistance can only be overcome by a stout 
and good long labor, evincing the power of the constitution, not 
only to bear the child, but to get the women well out of the lying- 
in chamber. You will find such weak pale women, complaining 
of pains and obstructions after delivery, that make you infer a de- 
viated womb. I think in such case, a physician is in duty bound, 
even where the signs are doubtful, to ask for the examination, and, 
if requisite, to assign his motives for such a request. I have a 
patient whose uterus was retroverted a few years ago, after her con- 
14 



210 PREGNANCY CAUSES RETROVERSION. 

finement, since which time, she has had two children. She has had 
it turned over so many times since, that she now knows perfectly 
well, when the accident takes place, and sends me word. If I 
ask her if it is retroversion again, she replies in the affirmative, 
and asks to be relieved. I am sure I have reposited it more than 
a dozen times. I have never known her to have it in pregnancy, 
however. She is now enceinte about three months, and the organ 
is in a proper position. I expect, after the birth of the child, that 
the round ligaments will again be found relaxed, and then the 
womb will again let its fundus fall down. 

When you shall have charge of a retroversion in a pregnant 
woman, lay it to heart, that a most solemn obligation is upon you, 
to treat the case with a conscientious regard to her safety, as well 
as that of the unborn embryo. Such a case is always dangerous. 
For, to say the least, it endangers the life of the foetus, and if un- 
cured, will probably, if not assuredly, cost the life of both parties. 
This is a solemn consideration, a consideration that becomes ex- 
aggerated by the prospect of the most dreadful and hopeless suf- 
fering for the patient, if she be badly treated. 

To suffer an abortion is always a risk, but to suffer an abortion 
brought about by so strained and unnatural a posture and con- 
finement of the womb, must enhance the risk immensely, though, 
it is true, that when the uterus cannot be reposited, while the gra- 
vidity continues, sve are authorized, and even commanded, by a 
sense of duty, to bring on the abortion, in order to enable us to 
save the woman's life, by arresting the further development of the 
child-bearing organ. One may take comfort to himself, however, 
in the instances of advanced pregnancy in retroversion, by con- 
sulting some of the wonderful escapes that are recorded in the books. 
And I am going to give you the account of one of them by Dr. 
Weir, which I quote from Ingleby's Obstetric Medicine, p. 12. 

"We are indebted to Dr. Weir, of Glasgow, for one of the most 
important cases of this nature hitherto recorded. See Glasgow 
Med. Journal, vol. i. No. 3, p. 262. This patient had taken 
strong purgatives with the view of procuring abortion. For some 
days prior to Dr. Weir's attendance, the urine had dropped away 
involuntarily, and now the abdomen was swollen by a firm tumor, 
painful on pressure, and occupying the sub-pubic region. The 
vagina was filled by a tumor regarded as the uterus in a state of 
retroversion, although the uterine orifice could not be reached. 



211 

This tumor not only pressed upon the bladder, and prevented the 
free discharge of urine, but nearly obliterated the rectum also, yet 
the bowels responded to the action of medicine. Urine was drawn 
off repeatedly by the catheter, varying in amount from two to four 
pounds in the twenty- four hours, and yet the sub-pubic tumor was 
only partially lessened. The lower extremities as well as the ab- 
domen became cedematous ; the tumor in the vagina approached 
nearer and nearer its orifice ; every distressing symptom was in- 
creased, and it was now impracticable to pass any description of 
catheter the requisite distance into the bladderr A smaller quan- 
tity of urine was each time drawn away, and the bladder reached 
considerably above the umbilicus, whilst the fundus uteri was 
progressively descending, the uterus being ultimately turned al- 
most upside down. About the tenth day from commencement of 
the severe symptoms, pains ensued resembling the pains of labor, 
and- owing to the strong action of the abdominal muscles forcing 
the uterus still lower, the introduction of the fingers into the va- 
gina proved exceedingly difficult. The condition of the patient 
had now become desperate, and it was essential to attempt her 
relief almost at any risk. The puncture of the bladder, (previously 
contemplated,) was abandoned under a well-founded conviction 
that such a measure would have little or no effect in bringing 
down the uterine orifice. The puncture of the fundus uteri was 
also suggested, but prior to its adoption, it was determined to 
make a last effort to reach the orifice. 'After much difficulty, 
and a great degree of force, and in opposition to the strong and 
powerful exertions of the patient, I succeeded in getting my hand 
into the vagina, forced up my finger above the pubes, and reached 
the mouth of the womb. An assistant at the same time got his 
hand into the rectum, and we had thus the perfect command of 
the patient. By steadily pushing upwards the fundus, and cau- 
tiously pulling the neck and mouth of the womb downwards, the 
tumor was gradually raised above the promontory of the sacrum, 
and the uterus reduced to its proper position.' A considerable 
quantity of urine was discharged during this proceeding; the pu- 
bic tumor disappeared ; labor progressed, and a four months foetus, 
putrid, was extracted about twenty-four hours aft or the uterus had 
been replaced. Severe abdominal inflammation ensued, which 
demanded vigorous depletion ere the patient was safe. She per- 
fectly recovered." 



212 m. 

Here is another case taken from the 1st vol. p. 217, of Dr. 
Moreau's Traite Pratique des Accouchemens . It was communi- 
cated to Dr. Paul Dubois, of Paris, by Dr. Mayor, of Lausanne. 

"S. G., an ignorant peasant woman, set. 32, who had borne 
three children, being assisted in her last two by her mother-in-law, 
ignorant as herself, was three and a-half months pregnant, when, 
on the 7th Nov. 1836, she was attacked with wandering pains; 
though the pain did not prevent her going out about her affairs: 
she said, in her trouble, it might be that she would die the next 
day. 

"Upon coming home about 8 P. M., she went to bed, and was 
soon seized with sharp pains in the belly and loins, that made her 
cry out aloud, and which the mother-in-law supposed were fore- 
runners of a miscarriage ; this was at 9J P. M. At 10^ the 
husband, who was assisting her for some purpose, discovered a 
large substance escaping at the genitals: being alarmed by this 
and the hemorrhage and pain together, they began to think of 
calling in a physician. The husband went to the midwife of 

M , a neighboring village, who, reaching her at one o'clock, 

found an enormous tumor outside of the vulva, attended with 
anomalies so extraordinary, that she insisted on having the 
opinion of an experienced accoucheur. The husband ran to Mr. 
C, who arrived at 3 J A. M. 

"After some inquiries into the nature of the tumor, the surgeon 
ascertained that it was the womb in a complete state of retrover- 
sion, and he succeeded in pushing it back and restoring it to its 
natural position. But the woman, who was already in the most 
deplorable condition, expired at half past four A. M., very soon 
after the reduction of the organ." 

The patient's death would have passed without remark, as one 
of the events that sometimes occur in abortion or hemorrhage, 
had not rumor attributed it to criminal designs. 

The authorities, therefore, ordered the autopsy for three o'clock 
on the 10th, fifty-seven hours after the decease ; and Messrs. M. 
& C, two well informed and well known surgeons and accouch- 
eurs, were appointed for the purpose. Their proces-verbal con- 
tains the following account : 

"The external genitals exhibit nothing peculiar; but when 
slightly separated, they exhibit at the depth of one-eighth of an inch, 
towards the fourchette, a ragged wound. The vagina is smooth 



m. mayor's case. 213 

to the touch and the neck of the uterus, firm and unengorged, is 
found resting upon the symphysis pubis. The vagina is very re- 
laxed, and the body of the womb, when raised, is very movable. 

"We opened the abdomen, and sawed asunder the ossa pubis 
in order to obtain a better view of the organs, contained in the 
cavity of the pelvis. The bladder, which was very large and flac- 
cid, containing no urine, was raised above the pubis, and appeared 
to have been distended ; in other respects it was unaltered, and 
partially concealed the body of the womb. This organ, pyramidal 
in shape, was six inches in length by five in breadth. It was soft, 
flaccid, reddish, and showed several ecchymoses, and small semi- 
circular lacerations, as if cut with the finger nails. Discovering in 
front of the sacrum, in the peritoneal lining of the pelvis, a trans- 
verse wound, we found the womb communicated with the posterior 
inferior part of the vagina, so that the vagina communicated with 
the abdominal cavity. Here, then, was an accidental canal, whose 
upper orifice was formed by a rupture of the peritoneum, its lower 
by a laceration of the vagina, and of which the middle portion 
occupied the lacerated recto-vaginal septum." 

" Upon pushing the body of the womb into this opening, we 
found that it passed without difficulty through the inferior opening 
near the fourchette ; and thus we observed the position of the 

womb when it was seen by M. C , during the woman's life." 

I shall not cite any of the remaining passages of this case, pre- 
sented by Dr. Moreau. They consist of stupid interrogatories of 
the lawyers who were concerned in the trial of the accused. The 
foregoing are enough to show how great is the power to bear 
down, (tsLvaapos,) in a strong woman like this peasant, who, under 
the irritation of her tenesmus, actually drove the body of her re- 
troverted womb through the posterior strong wall of the vagina, 
and fairly pushed the whole organ out of the genitalia, the fundus 
hanging down betwixt her thighs, and the os tincae looking up- 
wards into the pelvis. It is truly an extraordinary case, and one 
well calculated particularly to impress your minds not only with 
just ideas of the serious importance of the malady, but to show 
how powerful is the resistance a strong woman is able to make 
to your attempts to reposit, when her tenesmic force is excited, 
and beyond the control of her will. 

It sometimes happens that the surgeon cannot succeed with the 
two fingers of the right hand, in carrying the retroverted womb so 



214 



RETROVERSION. 



Fkr. 2. 




far upwards, along the curve of the sacrum, as to compel it to 
rise above the promontory of the bone, and thus be 
set at liberty from its imprisonment in the lower basin 
of the pelvis. In order to effect this, the fingers are 
required to be longer than the usual length. 

By means of the little instrument, of which the ad- 
joining figure is a representation, you will be enabled 
to carry it much farther than with the fingers. The 
instrument is made of steel, and it is conveniently 
curved to suit the form of the back part of the excava- 
tion. Conducted along the left indicator finger, to the 
cul-de-sac, behind the vaginal cervix, it may be 
pressed against the overset womb, which is readily 
pushed upwards by it. It is also a convenient instru- 
ment for drawing down the cervix from near the 
pubis ; — that part of the organ being taken hold of by 
the ring. The whole instrument, from the top of the 
ring to the end of the handle, is just eleven inches 
in length. 

It is made by Mr. John Rorer, and also by Mr. 
Schively, of Philadelphia. 

As I have found it a most convenient and useful 
apparatus in the management of retroversion, I 
heartily recommend it to you. 

I beg you to be careful in your diagnosis; always 
be very careful. 
If you love your profession, and would keep up its dignity, and 
your own, do not make mistakes. Do not suppose you have a re- 
troversion, when, instead of that, you are called to a case in which 
an enlarged ovary has fallen down in the pelvis. Such a tumor 
might fill up the w T hole of the space betwixt the sacrum and the 
bladder, lifting the womb up and jamming its cervix against the 
pubis. In such a state of things, should you seek for the os uteri, 
and find it up at the pubis, and also find a rounded mass thrust- 
ing the posterior vaginal wall forwards, you would be in great 
danger of making a false diagnostic. 

The pathognomonic mark of a retroversion is the os uteri not 
beneath, but above the crown of the pubal arch, while the cervix 
can be traced with the finger backwards to the body, which presses 
the posterior wall of the vagina forwards and downwards, giving 



RETROVERSION. 215 

the sensation of a mass or tumor, which is hard or firm in the non- 
gravid, and softer, or yielding in the gravid womb. If you should, 
in your early career, meet with a retroverted gravid womb, and 
make prudent attempts at reposition, after all the preliminary 
measures have been fully attended to, you might prefer to obviate 
the inflammatory engorgement by venesection, the bath, emollient 
cataplasms, anodyne enemata, or doses of anodyne medicines, and 
very scrupulously attend to the evacuation of the bladder, in hope 
of meeting with such success as Dr. Ingleby justly boasts of ob- 
taining in the case I quoted from him. 

But when, after consistent attempts, you shall have ascertained 
your failure, you ought, if possible, to introduce a sound into the 
os uteri to rupture the ovum, and discharge the liquor amnii. After 
which you might expect to succeed in your manipulation by the 
vagina, or by the rectum. But as it will in some instances be 
found impracticable to get the sound into the os uteri, you have 
the last resource of puncturing the membranes, by means of a 
curved small trocar, carried into the uterus itself. This is a 
dangerous operation, because, as the peritoneum descends be- 
hind the womb, on the vagina, you must necessarily make two 
wounds in it; and thus expose the. patient to the danger of a 
wounded serous membrane, besides that of a wounded uterus. 
A statement of the circumstances and motives would always, 
however, leave your skirts clean, provided the circumstances and 
motives have both been well weighed, and perfectly apprehended 
by you. 

Your writers will tell you, that when the womb is reduced or 
reposited, the woman should lie on a bed with her hips elevated, 
or some of them advise her to lie as long as possible on the face. 
As to this piece of counsel, you ought to judge from the circum- 
stances. If the case be one of non-gravid retroversion, the best 
position for renewing the difficulty would, I think, be the dorsal 
decubitus; and I should much prefer to lay the patient on the hip, 
slightly inclined forwards. In the gravid case, if the pregnancy- 
have proceeded as far as the second month, and a fortiori, if to 
the third month or more, it is extremely improbable the accident 
will be repeated if the urine be regularly drawn off, for the uterus 
is too long to fall over without reluctance and force. 

If you deem the case one not unlikely to relapse, you should, if 
not living near enough to render aid yourself, at the proper seasons, 



216 RETROVERSION. 

give the patient directions as to the use of the catheter, and in- 
struct her to introduce it every four or six hours, so as to make 
sure that no bladder-tension shall overthrow the womb again 
during your absence. 

When you can venture to employ a pessary, which you cannot 
well do in the pregnant female, you should adjust one of suffi- 
cient magnitude to produce or extend the vagina. I say extend 
the vagina, and I say so, because there will be scarcely a relapse 
if you keep the vagina stretched to its full length. When it is so 
stretched, it carries the uterus upwards, and makes it move up- 
wards coincidently with the curve of Dr. Cams. In order to a 
first retroversion, I esteem it indispensable that the whole womb 
should descend, see-sawing backwards ; for I cannot irnagine a 
retroversion, as taking place with a vagina four and a half or five 
inches long. Try the case in your own judgment ; think how a 
womb could be retroverted, while it stands so high up in the 
pelvis. If you perpend the question carefully, I believe you will 
decide that it cannot be turned over by the bladder, without first 
descending along Cams' curve, so as to enable the fundus to get 
down lower than the promontorium, and when once down there, 
the tenesmus will complete the oversetting of it. 

I have many times reposited a non-gravid womb, that had long 
been retroverted, and placed beneath it one of Dr. Physick's globe 
pessaries, of two and a half inches diameter. Such a pessary 
will keep the womb in its place pretty well ; but, if the round 
ligaments have lost all their tone, a full bladder, aided by a fit of 
sneezing, laughing, or in straining at stool, will readily overset it 
again. I speak of the non-gravid womb, which, you know, is 
about two inches long, more or less. 

You might well imagine that, when the womb is supported by 
such a pessary as I have just mentioned, the retroversion might 
take place upon the emptying of the bladder, — because, as the 
posterior wall of the bladder comes nearer the pubis, the less the 
water within it ; so the anterior face of the w r omb, which is attached 
to it, must also approach the pubis ; and being only two inches in 
length, and without support from its ligamenta rotunda, would rea- 
dily tumble over backwards. I say that this is, to my knowledge, 
the case; and I say so, being grounded upon observations made, 
over and over again, especially in three individuals, whose names 
I have no right to make public. In all these women, I have repo- 



RETROVERSION. 217 

sited the uterus completely, and it has fallen over again imme- 
diately. I have reinstated it, and again it has become displaced: 
nor could I get it to stay in situ, until I had supported it at a great 
height, by means of Dr. Blundell's stem-pessary. 

I have, in fact, come at last to the conclusion, that in one of 
those exceedingly relaxed cases of round ligament, where the womb 
falls over as soon as you put it up, it is pretty much a hopeless 
task, the attempting to sustain it by any other than the stem- 
pessary. Yet, in a case where the uterus does not at once turn 
over again, after being reposited, I conceive the globe the least 
inconvenient, safest, and surest of all remedies. 

If you prefer to make use of Dr. Dew T ees' disc, you can do so ; 
but I apprehend a careful inquiry into the relative power of eleva- 
tion of the two sorts of pessaries, will bring you to the conclusion 
that a two inch globe will lift and hold the womb much higher than 
a three inch disc-shaped instrument. As for the sponges and other 
horrid conceits of the sort, they are too detestable to be thought 
of. I disapprove of the glass ones — when strong, they are too 
heavy, when light, too frangible. A cork pessary is bad, because 
the wax that covers it comes off, and leaves the rough cork in 
contact with the parts. Such contact is dangerous — it is ulcera- 
tive. 

Do you expect I should say something moreof those utero-abdo- 
minal supporters ? I deem them abominable. I have never used, 
and never shall use one of them. To think of curing a retroversion 
or prolapsus with them, is an anatomical absurdity. But I shall 
not dwell on them, because you w T ill not forget what I said of 
them in my lectures. 

I have w T ritten you a very long letter on retroversion, perhaps 
too long ; and yet there remain many things I could say. Let us 
recapitulate before I close, some of the opinions expressed in this 
letter. 

1. Retroversion consists in the turning of the top of the womb 
over towards the sacrum. The fundus uteri dips down into the 
hollow of the sacrum, and the posterior surface of it comes into 
contact with the posterior surface of the vagina, which it presses 
forwards and downwards towards the os externum, making a 
tumor there. The os uteri is directed up against the bladder, 
which it pushes against the symphysis pubis. 

2. It causes dysuria, or retention of urine ; or at least, mictu- 



218 RETROVERSION. 

rition. It also gives rise to pain in the course of the round liga- 
ments, and the ligamenta lata. It is attended with pain in the 
region of the sacrum, loins and kidneys, and there is a sense of 
weight, pressure, or bearing-down, in the hypogastrium and pelvis. 

3. When it occurs in the pregnant woman, it is fraught with 
danger both to the mother and child. If uncured, the mother is 
likely to be the victim of a dreadful death, from pain, inflamma- 
tion, and from total obstruction of the pelvis. 

4. The more advanced the pregnancy, the more dangerous the 
accident. 

5. It is a diseased or debilitated state of the round ligaments 
that gives rise to the disorder. The cure consists in the restora- 
tion of the health and tone of those ligaments. 

6. It is in some cases incurable, from adhesions tying the womb 
down in the excavation. 

7. It should be treated — 1st, by evacuating the bowel; 2d, by 
drawing off the urine ; 3d, by repositing the womb ; 4th, by sup- 
porting the reposited womb with a pessary; 5th, by carefully en- 
joining an attention to the state of the bladder, which should never 
be allowed to get too full. 

8. Lastly, I ask you why a pessary should be able to cure the 
round ligaments? I am sure of your answer. It is this: every 
tissue of living beings that is not compelled to extend, has a 
tendency to condense or contract itself. This is true, whether of 
muscle, cellular tela, lung, skin, and all the rest. While the 
round ligaments are extended by an overturned womb, they can- 
not become shorter, they cannot exert their natural tendency to 
condensation. To lift up the womb, and keep it up, to empty 
the bladder, and prevent it from being overfull again, is to give to 
the round ligaments an opportunity to act out their nature — that 
is, to regain their natural length, strength, and tension — which is 
effected by time, by tonics, by wholesome food, and by whatever 
tends to consummate the state which you call health. Take care 
that when they do recover, they go not beyond the state of reco- 
very, and contracting too much, bring on the very antithesis 
of retroversion, I mean an anteversion of the womb, which shall 
be the subject of my next letter. Farewell. 

C. D. M. 



ANTEVERSION. 219 



LETTER XVII. 

ANTEVERSION OF THE UTERUS. 

Gentlemen : — The state of the uterus described in my last letter, 
under the title of retroversion, is much more common than its op- 
posite, the anteversion of the organ, a case in which the fundus 
is drawn or pressed towards the bladder of urine, and permanently 
maintained in that position. In such circumstances, the external 
signs are perhaps not different from those that attend upon the 
retroverted state; and they consist chiefly of pelvic pain, misery, 
bearing-bown sensation, micturition, and pain and weakness of 
the lumbar and sacral region, which are increased by exercise, 
and by the standing position. I do not think that I should be 
able, from any complaint, or relation proceeding from the patient, 
to discriminate between the affection attendant upon the ante- 
verted and the retroverted state of the organ ; nor do I suppose 
that any physician could correctly and confidently make such a 
discrimination, except upon information acquired by means of the 

TOUCH. 

I said that the anteverted is not so frequently met with, as the 
retroverted deviation. I am, indeed, of opinion that it is a rare 
malady, for, in more than thirty years, I have had few opportu- 
nities of observing it, whereas, I have met with a very consider- 
able number of the contrary sort ; a number so great, that I think 
it not very much disproportioned to simple prolapsus, as to fre- 
quency of occurrence. 

The anterior face of the non-gravid womb, as high up as the 
middle of the corpus uteri, is in contact with the bladder; which, 
as I remarked in my former letter, pushes the womb backwards 
when filling, and draws it forwards towards the symphysis pubis 
as it becomes emptied ; the round ligaments being put upon the 
stretch in the former, and completely relaxed in the latter pro- 
cess. 

The only natural anatomical power that can draw the fundus 
uteri to the pubis, is to be found in the bladder of urine ; — for the 



220 ANTE VERSION. 

round ligaments do not, as a physiological act, draw the womb 
nearer to the pubis than the middle of the pelvis, where it ought 
to be coincident, as to the direction of its axis, with the curve of 
Carus; whence it appears to me, that in all cases where the fun- 
dus uteri is permanently drawn against the bladder, and near the 
pubal bone, we must resort to one of two modes of explanation of 
the occurrence, one being, that it is pushed there by some body 
lying upon and behind it; and the other, that it is drawn or pulled 
in that direction by the ligamenta rotunda, which have become so 
short as to prevent the womb from retracting towards the sacrum 
when the bladder, being full, tends to send it off in that direction. 
Here, then, are two possible causes of anteversion ; one, pressure 
from above or behind; and the other, traction or drawing from 
before. 

Now, the causes that might act on the organ from above and 
behind it, are tumors fallen down into the pelvis, or developed 
in its superior parts; which, by their weight or volume, compel 
the uterus to assume a sort of horizontal attitude, pointing the os 
uteri backwards, and the fundus forwards; — or, the compressing 
cause may consist in a tumor, or tumors developed on the supe- 
rior and posterior parts of the corpus and fundus uteri, extending 
backwards in their growth, until meeting with a point oVappui on 
the back part of the pelvis, and unable to extend farther in that 
line, continue to grow, but always finding space by thrusting the 
organ from which they spring towards the bas-fond of the blad- 
der. 

Doubtless such may be the true rationale of some of the cases, 
yet admitting this to be true, it is still clear to me, that a con- 
traction of the ligamenta rotunda is much more generally the 
cause of anteversion. I can form no other conclusion from my 
own observations, and, on several occasions, I have had opportu- 
nities to test the thing in my practice ; I having, in some of the 
samples, in vain tried to push the fundus off from the vicinity of 
the pubal symphysis, with one, or with two fingers, introduced far 
upwards behind the shear-bone. Upon making such attempts, 
having failed to move it out of its fixed position, I have been 
obliged to adopt the opinion, that the womb was tied down by a 
contraction or condensation of the tissue of the ligaments, so often 
named. What other opinion, indeed, could, or can be reasonably 
adopted in a case where the most careful exterior palpation clearly 



ANTEVERSION. 221 

proved that no tumor, fallen from above, or developed behind the 
womb, had pressed it against the front bone of the pelvic cavity. 
I saw to-day, June 10th, a case in which the womb was jammed 
hard against the pubis, by a tumor in the pelvis. 

It is pretended that the front, or the posterior half of the womb, 
may, by some vicious condition of the development force, grow to 
so great a size as to overthrow the womb, either in a backward or 
in a forward direction. 

I have not had any opportunities of seeing such samples, and 
cannot, therefore, speak from experience, as to such causes of ante- 
version. I may, however, say that I have met with several cases 
of unequal lateral development of the uterus, giving to the organ 
a tendency to fall or become oblique,, to the right or the left side, 
according as the right or as the left symmetrical half of the womb 
was the largest. 

Dr. Tiedemann showed me two or three such specimens, in 
the Anatomical Museum at Heidelberg, in 1845, and I have had 
two such in my own collection. It should be observed, that as 
the uterus originally consists of two symmetrical lateral halves, we 
might reasonably expect to meet with such unequal developments 
occasionally. It is probable the other sort, or that wherein the 
anterior and posterior halves are so unequally developed, must be 
from the nature of the embryogenic development law, much more 
rarely observable. 

Allow me to repeat, that I have not met with a great many in- 
stances of anteversion. In all that I have met with, however, 
there has been left upon my mind, after careful exploration, no 
doubt as to the shortening of the round ligaments ; and why not ? 
The round ligaments are very subject to disease, being often in- 
flamed after parturition ; so much so, as to constitute a cord as 
large as the fore-finger of a man, or even as large as a thumb, 
very painful upon pressure, and traceable in its course not only 
through the abdominal canal, but backwards towards the angle 
of the womb, through the thin integuments of a scrawney woman. 
I have met with several samples of this sort, that I have been 
obliged to treat by leechings, fomentations, cataplasms, and by 
small doses of tartar of antimony and potash. 

Morgagni, in his forty-fifth epistle, tells us, that he found them 
so in his dissections. He regards them as constituted chiefly of 
blood-vessels; but Velpeau considers them as endowed with a 



222 ANTEVERSION. 

considerable portion of muscular fibres. I deem it quite reason- 
able in M. Velpeau, to hold such an opinion, since, as they spring 
directly from the womb, and proceed to be inserted upon the ex- 
terior of the pelvis, they could not but carry with them a structure 
like that of the womb, as well as like that of the Fallopian tubes, 
of whose muscularity no doubt can be entertained. 

Seeing, then, that the womb naturally rests on the top of the 
vagina; that it is wholly without attachments on its posterior face ; 
that it has none but those of the two ligamenta lata on its sides, 
and that its only connection in front is a partial one to the blad- 
der, and its sustentation by its round ligaments, we cannot doubt, 
when we find it held firmly against the pubis, of its being held 
there by means of some tumor behind or above it, or by a pair 
of contracted ligamenta rotunda; contracted, I say, either by a 
simple process of hypertrophy, by the consequences of inflamma- 
tion, or by some spasmodic innervation of its muscular fibres. 

To cure it, we must push the top of the womb off from the vi- 
cinity of the pubis, or we must cure the ligaments of their hyper- 
trophic or inflammatory vice. 

It is possible that Dr. Grauiex's seton, mentioned at page 58, 
Letter V., might profitably be applied to the subduction of the 
morbid activity of the ligaments, and in any case where the pes- 
sary and other means of countervailing pressure should be deemed 
inadmissible, I hope you would take into consideration the ques- 
tion of this especial seton. You are aware that the seton, in a 
cure, is like money in the funds, it works while you are asleep, 
it works day and night, for weeks, and months, and in general, 
only well, only with beneficence. I advise you to think of the 
seton, therefore. I confess I have not met with the case that I 
have deemed suitable for its trial, but I should certainly recom- 
mend it to a patient of mine, whom I should deem likely to be 
benefited by it. 

The pessary, after all, is the most probable and most convenient 
remedy. 

A globe of two and a half inches, will lift the uterus very high 
upwards in the pelvis. Its action must be to push the womb up- 
wards and backwards, and therefore to resist the contractility of 
the round ligaments. But, by resisting it steadily, gently, and 
protractedly, it will at length draw them out, elongate, stretch, or 
restore them to their due and normal length; which, being done, 



FLEXION OF THE WOMB. 223 

the globe maybe removed, and the filling of the bladder entrusted 
with the business of maintaining them at their proper longitude, 
for the rest of the patient's life. Such a patient, even while under 
treatment by the pessarium, should be advised to keep her bladder 
pretty full. A bladder of urine, containing sixteen or twenty 
ounces of fluid, would be a very powerful antagonist of the con- 
traction of the ligamenta rotunda. This is one of the cases in 
which a mere verbal order, or talking explanation will not answer 
your purpose. You ought to take out your pencil, and making an 
intelligible sketch of the parts interested in producing the incon- 
venience, show to the woman, and convince her of it, that if she 
will not carefully push the womb away from the pubis, by filling 
her bladder quite full every day, and more than once a day, she 
need not very confidently expect to remain cured, even if you 
should cure her. 

Before I close this letter, I must take occasion to say, that Mr. 
Warner, whose name I mentioned before, makes for me an egg- 
shaped pessary, larger than a hen's egg. He can make them for 
you of any ordered size. I have found this ovi-form pessarium 
very useful in anteversions. I adjust it with the lesser pole of 
the egg directed to the os tincse. The greater pole is in the lower 
part of the vagina, just above the grasp of the sphincter. I think 
such a shaped instrument serves to stretch the ligaments more 
effectually than any other. 

There is a state of the womb called flexion of the womb, which 
may be either a retroflexion, or an anteflexion. In this condition 
the organ is bent, either forwards or backwards, and the bend, or 
angle is found in the neck. 

Madame Boivin says the flexion is found at the junction of the 
cervix and corpus ; and she is of great authority. I have seen, 
and I possess one such specimen ; but this is the only one I have 
seen; whereas I have met with a considerable number of in- 
stances in which the bend took place in the true cervix, far bo- 
low the corpus, and sometimes in the vaginal cervix itself. I 
have now under treatment a young married lady, in whom the 
vaginal cervix is bent very nearly at a right angle to the long 
diameter of the womb ; whose fundus is strongly held by a con- 
tracted state of the round ligaments, close against the pubis. In 
those cases of diseased uterus wherein we find the womb grown 
solid, and as large as the healthy uterus, at four or five months 



224 FLEXION OF THE WOMB. 

of pregnancy, we rarely fail to find the cervix bent like a retort 
neck. 

I do not know any general signs by which flexions of the womb 
can be diagnosed, save those discoverable by the touch, and they 
are so clear as hardly to be worthy of description. Everybody 
knows that the womb is straight ; and where it is found bent into 
a curved, or an angular form, it is a case of flexion ; anteflexion 
if the re-entering angle is forward, and retroflexion, if the salient 
angle is turned towards the front of the excavation. 

Many women have the cervix uteri very slender; some of them 
are not bigger than the little finger. Now, if a woman with such 
a slender, flexible, and weak cervix, should have some degree of 
descent of the womb, it might happen that the long slender cer- 
vix, being driven, or having descended far enough to rest, upon 
the posterior part of the pelvis, or even on the posterior wall of 
the vagina, should bend with its own weight and any superadded 
weight, so that the cervix would cease to be straight ; but, become 
curved or angular ; and after being kept so for many months, 
would acquire such a form, as its permanent character. 

I deny not that other causes besides direct pressure, might give 
to the cervix uteri this distorted appearance; such causes might 
be intrinsical ones, depending on some development of the pos- 
terior or anterior half of the cervix, causing the anterior, or the 
posterior half to be too short. Such an unequal development 
would certainly bend it. There can be no doubt that such is the 
case as to those lateral curves that I spoke of in a former part of 
this letter as having been shown to me by the good Professor 
Tiedemann, at Heidelberg. 

I do not know that these curved or angular conditions of the 
cervix are, in themselves considered, to be esteemed as matters 
of any very great consequence. I have not any reason to sup- 
pose that they cause the patient to experience any pain, or any 
distress. My opinion is that they are chiefly to be regarded as 
signs and accidents of a displacement of the womb, and that the 
indication is to support the womb, which being done, the curve 
will disappear. However, it should be observed that if the curve 
is a development fault, no lifting up of the uterus will be likely 
to do any good, as far as the curvature is concerned. 

It is probable that w r here this curve or angle of the cervix uteri 
exists, there will be little probability of the womb ever becoming 



FLEXION OF THE WOMB. 225 

fruitful. To cure it, will be perhaps to remove the barrenness. 
I say this, though I am aware it has been asserted that curvatures 
are met with, even in the pregnant female. I deny not that Bau- 
delocque may have met with curvatures in the gravid womb, but 
I do contend that any such curvature is a very different thing from 
the angularities we are speaking about. 

You may see in the plate 11, figures 15, 16, 20 and 21, of 
Wigand's Geburt des Menschen, 2d edit, by Dr. Froriep, samples 
of this distortion in. the gravid uterus, but they are all lateral 
curves; and I pray you to remember that symmetrical halves 
are governed by laws quite different from those that rule over 
opposite halves, at least in all the true Zygozoars. Wigand 
says of these unequal sides : " Die pradisponirende Ursache dieser 
s'ich so allmalig und erst wahrend der Geburt, und selbst bei der 
normalsten Kopf-oder Steifslage entwickelnden schlecten Configu- 
ration des Uterus, scheint auf einer gewissen abnormen ange- 
bornen structur-oder Entwickelung der Bewegungsfasern der 
Gebarmutter, und einer daher ruhrenden krankhaften Neigung 
derselben zu partiellen, unregelmassigen Contractionem zu be- 
ruhen." — Geburt des Menschen, p. 75. 

The predisposing causes are, in Wigand's opinion, to be 
sought for in a certain original deviation in the structure or deve- 
lopment of the muscular fibres of the uterus, and a consequent 
tendency to partial and non-coordinate contractions in labors. 

But, after all, I deem there is but little profit in so much dis- 
cussion; the gist of the matter being essentially the cure. But 
how to cure it! Some have proposed to pass up a small spatula 
of wood (it might be well denominated a peg), into the canal of 
the cervix, to straighten the bent cervix, by leaving it in situ. 
Such a process of spitting or skewering the womb, appears to me 
ridiculous. The more especially, as I have always found that 
when I had straightened the cervix with the pressure of my 
fingers, it would always immediately recover its curvature with a 
spring, as if made of caoutchouc. 

To wear such a skewer or peg as has been proposed, would 
be merely to hurt the woman, not to cure her womb ; pray don't 
try it. 

But, how to cure it! that's the question. I do not know any 
other method than lifting the womb up. If it be a case of ante- 
flexion, lift up the womb to stretch off the ligamenta rotunda ; if 
15 



226 FLEXION OF THE WOMB. 

a retroflexion, raise up the womb to let the ligamenta rotunda 
contract, and condense themselves. You see that the pessarium 
is in this case, in the same predicament as the Satyr's guest on 
the mountain, who blew his fingers to warm them, very reasona- 
bly, and then blew his porridge to cool it, which was also quite a 
reasonable action. Don't you, like the Satyr, turn him out for 
blowing hot and cold with the same breath. That Satyr was but 
a Satyr at best. "What reason, then, had Father iEsop to expect 
philosophy in such a beast, or to set him up as an example of 
wisdom and justice? If it be a retroflexion, use a large globe; if 
it be an anteflexion, take an oviform pessary of silver gilt, and 
choose one as large as a Normandy hen's egg; adjust it, so that 
the lesser pole of the egg shall look towards the uterus, while the 
larger pole shall lie in the lower segment of the vagina. I have 
found such an one efficacious in pushing off the uterus from the 
bladder, and at the same time in producing or elongating the tube 
of the vagina. 

I said, in a note to Colombat, p. 150, that I had met with but 
one sample of the true anteversion of the womb up to the date of 
that writing, which was nearly three years ago. Since that I 
have met with several cases of anteversion. 

I had seen many instances in which the vaginal cervix was 
angular, either in the anteflected or retroflected form, but they 
were instances derived evidently from the pressure of the flexible 
cervix, against the posterior wall of the vagina, and did not in- 
terest the principal portion of the long axis of the uterus ; proba- 
bly such cases scarcely deserve to be classed among the true ante- 
flexions of the organ. 

I shall say nothing in this letter as to the lateral obliquities of 
the womb. I shall probably advert to them when I come to speak 
with you on the disorders and accidents of pregnancy. In my 
next, I shall offer you some observations upon inversion of the 
womb, several samples of which have fallen under my notice. 

I am, &c, C D. M. 



INVERSION. 227 



LETTER XVIII. 

INVERSIO UTERI. 

Gentlemen : — The term Inversion of the womb, is applied to 
express that state in which the uterus is turned inside out ; as a 
stocking or a glove is turned inside out by drawing it off the foot 
or the hand. 

Dr. John Green Crosse, of Norwich, in England, published in 
1845, an 8vo. volume, Part I., entitled An Essay Literary and 
Practical, on Inversio Uteri, which is so full of learning, research, 
and that practical good sense that distinguishes all the writings of 
that able gentleman, that I am under no little temptation to give you 
the whole of it as a letter; but I should, in that case, violate the 
rule laid down, to render this volume as nearly as possible an 
original one. I shall only, therefore, advise you to take the first 
opportunity to read Mr. Crosse on the subject in question. Doing 
so, you will learn that he says at p. 8, 

"Inversion signifies not only a turning inwards of the uterine 
walls, but a turning inside out of the whole organ, by its passing 
successively through the os tincae, converting the lining mucous 
membrane into an exterior covering of the uterus, and creating a 
new cavity, which is lined with peritoneum, and communicates 
superiorly with the cavity of the abdomen." 

Mr. Crosse, in another paragraph, says, "inversion of the uterus 
is either partial or total; the latter can exist only in one degree, 
and admits of no subdivision. Partial inversion, on the contrary, 
comprises very many degrees, and there are both physiological 
and practical reasons for noticing and describing three, by way 
of classification, namely, depression, introversion, and perversion.^ 

Such are the divisions of our malady proposed by Mr. Crosse, 
and he next goes on to show, that depression, which is the slight- 
est degree of partial inversion, is present when any portion of the 
entire thickness of the walls becomes convex towards the cavity 
of the uterus. Introversion is the case where the depression has 
gone so deep, as to bring a part of the fundus within the grasp oi 



228 INVERSION. 

the portion of the uterus into which it is received. Perversion is 
when a portion of the fundus projects through the os tineas. 

This, then, is Mr. Crosse's classification, which, as you per- 
ceive, furnishes easy terms of communication, whenever in con- 
versation or in writing, you desire to treat of the several degrees 
of the accident in question. It serves, also, to keep in the re- 
membrance the fact, that where the womb is in danger of inver- 
sion, that danger may be greater or less, according as the accident 
has proceeded to a greater or less degree. 

You may know that the womb is inverted by several signs ; 
which are, pain, hemorrhage with its attendant phenomena, ab- 
sence of the uterus from its usual place, a tumor in the vagina, or in 
the womb, or depending outside of the vulva, also by a concavity 
felt in the fundus of the womb, instead of its natural convexity 
ascertainable by palpation of the hypogastrium. 

The causes of inversion are chiefly to be found in improper or 
accidental tractions on the cord in child-bed. They are improper 
whenever an ignorant person takes hold of the umbilical cord, to 
pull forth the after-birth, without first ascertaining that the womb 
is contracted ; the accidental causes are where too short a cord 
inverts the womb which has just forced the child into the world, 
aided in its contraction by the contraction of the abdominal mus- 
cles. A woman is sometimes suddenly delivered while standing 
upon her feet, or in rising from the close stool ; in such a case, the 
fall of the child towards the floor, is apt either to break asunder 
the cord, or if the uterus become suddenly relaxed, it may draw 
the adherent placenta still attached, and the whole fundus and 
body out at the genital orifice. 

A womb may also be inverted, by rudely pressing or kneading 
the hypogaster with the hand in order to enforce its contractility. 
To press rudely, in this way, upon the top of the fundus, and im- 
mediately expect the woman to bear down, is not very safe, since 
if a depression, as Mr. Crosse calls it, should have been produced 
by your palpation, and the woman should at once begin to bear 
down, she would probably convert the depression into an intro- 
version, then into a perversion, and so at length, into a complete 
inversion. Even the act of straining at stool, or at urine, after the 
delivery of the placenta is completed, might suffice to cause an 
inversion, provided it should be done at a moment, when the 
womb is lying within the belly flaccid, and loose as a wet bladder. 



INVERSION. 



229 



I have found the womb to fall down as it were spontaneously, 
seemingly because it was destitute of any solidity capable of resist- 
ing the ordinary pressure of the abdomen, even when not under 
a tenesmic irritation. 

A polypus, or other tumor, growing within the cavity of the 
womb, comes to be so large in the course of time, that it passes 
out of the circle of the os uteri, and takes possession of the vagina. 
Here is naturally set up a powerful uterine tenesmus ; the depres- 
sion makes its appearance, the introversion follows, and so from 
step to step, the patient lapses into true complete inversio uteri. 

The diagnosis of inversion in its different stages, is not without 
great difficulty in some of the cases. It is so in reference to the 
similarity of the appearances presented by some of the fibrous, 
and even by some of the cellular polypi, with those exhibited by 
the inverted womb, and as this special diagnosis is not only a very 
difficult but a very important one, I beg that you will always 
very seriously incline yourselves to great cautiousness and slow- 
ness, before you make, and especially before you announce your 
opinion of any case. 

Where you are called in to witness, and give counsel or aid, in 
an inversio uteri that has just taken place, you can have no diffi- 
culty in making a correct opinion. But in those that have hap- 
pened long before, and in which the womb, though inverted, has re- 
covered nearly its non-gravid size; take, I beseech you, very great 
care not to make a mistake ; don't think you are dealing with a 
uterine polypus, when you in fact are dealing with the womb 
itself; because, when people deal with a polypus they cut it off, 
when they deal with the womb, they let it alone, which is a very 
great and a very important difference. 

I repeat, that it is difficult in some of the instances, to discrimi- 
nate between the inverted uterus, and the polypus uteri. In 
neither is there an os uteri to be felt ; they are both reddish look- 
ing, softish, bleeding, rather insensible masses, about as large as 
the larger end of an egg 7 save when the polypus is larger; I mean 
in the chronic forms. 

In passing the finger or two fingers upwards in the vagina, a 
ring like what the French call a bourrelet, is felt through which 
the tumor passes outward, into the cavity of the vagina. If you 
look at them through a speculum uteri, you will scarcely be able 
from the light to discriminate betwixt them. 



230 INVERSION. 

You must carefully gather the whole history of the case, as for 
example by the following method. 

"What's your name?" 

"A. X." 
9 ' ' How old are you ? ' ' 

"Twenty-six." 

"Are you married?" 

"Yes, these eight years." 

"Had any children?" 

"Three." 

"When was the last one born?" 

"Six months ago." 

"Any trouble or difficulty at the birth?" 

" Oh yes, I flooded dreadfully." 

"Who attended you?" 

"Mrs. Lucina." 

"How was it with the after-birth? Did it come away soon?" 

"No, sir, it w T as a long time coming." 

"Did it hurt you?" 

"I guess it did, indeed; she pulled me so hard, I screamed till 
you could have heard me a square off." 

"Well, w T hat happened next?" 

" I don't know, for I fainted away and was a long time so weak, 
that I cannot tell what happened." 

"Did you flood very much?" 

"Flood! why I was fairly covered with blood." 

"How long before the discharges stopped?" 

"Why, it's never stopped in fact, for I am more or less unwell 
every day, especially if I do any hard w^ork." 

"You look very pale." 

"Bless your heart, I used to be as red as a rose." 

"Have you any appetite?" 

"Yes, pretty good, thank you." 

"How are the bowels, regular?" 

"Oh, no, quite costive." 

"Any trouble of making water?" 

"Very much; often obliged to go, and to get up at nights. It's 
a great trouble to me." 

"You must let me examine the case; I can't tell what it is ex- 
cept you allow that." 



INVERSION. 231 

"Well, I suppose if I must I must. But don't hurt me." 

"Not in the least, not at all." 

Now let the patient lie down on her left side, with her buttock 
near the edge, or foot of the bed, her thighs at right angles to the 
trunk, and the legs flexed ; a pillow betwixt the knees ; wash 
your hands with soap and warm w T ater; 1st, to cleanse them; 
2d, to soften them; 3d, to increase their tactile sense, for you 
ought to have that sense in its highest perfection. Anoint the 
index with oil, and Touch the patient. 

The tumor is as large as an egg, and contained within the va- 
gina. It is pyriform or ovoidal, and gives no pain. Push your 
index up along the root of the tumor to a sort of circle or cul-de- 
sac, which prevents the further advance of the finger. Touch it 
all round the tumor, in front, behind, and on the right and left. 
Introduce a Sedillot's catheter, and push the end upwards through 
the encircling bourrelet, to ascertain how high it will go, and 
whether it will go equally high all round the neck of the tumor. 
If it will go high on one side and not near so far on the other, the 
inference is, that you have not under care an inversio uteri, but a 
polypus uteri. If it go equally high all round, and not very high 
anywhere, the inference is strong in favor of an inversion. 

Now insert your Sedillot into the urinary bladder, after having 
put a cork into the outer end of the silver tube to prevent the 
urine from escaping. Keep it there while you pass the indicator 
of the left hand into the rectum, very far -upwards. Then, tak- 
ing the catheter in your right, turn the concavity towards the 
sacrum, and with your finger bent forwards towards the pubis, 
try to meet the point of the sound ; surely, if you will do this, you 
cannot fail to ascertain that no w T omb is to be found between the 
points of the finger and catheter, and therefore, the tumor in the 
vagina is the womb inverted. 

It was inverted at the time of her confinement, six months ago. 
Mrs. Lucina inverted it by pulling at the cord before the placenta 
was detached, and either did, or did not know what she had done. 
The hemorrhage was terrible. The woman ceased to bleed, and 
did not die, because she fainted so badly, that the vascular injec- 
tion by the heart was too feeble to kill her by hemorrhage. She 
slowly recovered in a measure, but bleeds still upon the smallest 
excess of exercise or labor. 

Well, now, my young friend, you have made your diagnostic; 



232 INVERSION. 

what are you to do for the patient? Will you reposit or reinstate 
this womb? You can't. You might as well try to invert one of 
the non-gravid uteri on my lecture-room table as to reposit this 
one. The time is gone by. You have no art or skill, nor no 
power equal to the performance of such a miracle of surgery as 
that. 

I can with difficulty, conceive of a more dreadful condition for 
lying-in woman, than that in which she is placed by a total inver- 
sion of the womb in labor. For example — here is a case that I 
have already published, in my Practice of Midwifery ; but which 
I think it right to republish in this letter. It is the case of Mrs. 
S., in S. 7th street, which occurred in June, 1831. 

It seems that having on both the preceding occasions suffered 
severely from the method adopted by the physician in removing 
the afterbirth, and supposing that a midwife would deal more 
gently with her, she engaged an old woman much accustomed, as 
it was said, to the care of women in labor, to attend upon her in 
this confinement. The child was born by a very easy labor, but 
the afterbirth not coming away so promptly as was desirable, trac- 
tions were made upon the cord which caused the afterbirth to come 
into the vagina. This gave the patient exquisite pain. The mid- 
wife, who could not understand why the woman should suffer so 
severely, made haste to draw the placenta forth by the cord, which 
made her cry out so loud that it was said her voice was heard in 
the street. When the mass came away, the good woman found 
it still adhering to something: she could not take it up and put it 
into a basin. She therefore continued to pull at it with great 
force, not knowing that she held in her hands the afterbirth still 
adhering to the fundus of the womb, which was now completely 
drawn forth and turned inside out. The hemorrhage was enor- 
mous, and the patient soon sunk into the extremest weakness and 
exhaustion. Half an hour elapsed before she thought proper to 
confess her incompetency to manage the case. I was sent for, 
after she had acknowledged her ignorance of the method of pro- 
ceeding, and when I arrived the patient was without pulse, very 
cold, suffering the extremest distress, with constant jactitation, 
and a thirst that was unappeasable. To all appearance the wo- 
man was in the agonies of death. I found the globe of the womb 
hanging down full half way to the knees, and still invested with 
the placenta and membranes, except where they had been torn 



INVERSION. 233 

and broken by the attempts of the midwife to pull the entire mass 
away, uterus and all. 

I endeavored to push the whole womb and placenta back into 
their natural position, but finding I could not succeed I sent for 
my venerable friend Dr. James, who speedily arrived. Dr. James 
now made an attempt to reposit the womb, but he also failed. 
By his advice I now removed the placenta, but could not force 
the uterus up into the pelvis. 

In making the attempt to restore it to its place, I followed the 
method recommended in the books, that is, I compressed the or- 
gan in both the hands in order to reduce its size. At last I ob- 
served that the more I handled it, the firmer and harder it became ; 
in short, that I excited in it the after-pains, just as we excite them 
by frictions on the hypogastrium after the child's birth. I therefore 
inferred that the proper way of proceeding would be to let it rest; 
and as soon as the relaxation of the organ should be complete, as 
it is in the intervals between the ordinary after-pains, to endeavor 
to indent its fundus, like the bottom of a bottle, and then carry it 
upwards. I found, upon observing it, that the womb repeatedly 
expanded or relaxed, and then contracted again, being soft in the 
former and hard in the latter state. Taking, therefore, the moment 
of the completest relaxation, I indented the fundus w T ith one fin- 
ger, and as it became more and more concave, I applied each of 
the fingers in succession, until I found that its further progress 
was impeded by the os uteri, w T hich, although it was completely 
inverted, yet resisted for some time the attempt at reposition. By 
a resolute perseverance, I finally had the pleasure to overcome the 
resistance, and the peritoneal surface of the fundus was pushed 
upwards beyond its os uteri, and at last the womb was found to 
be completely restored to its natural position, but still containing 
my hand, which was now up as high as a little above the umbili- 
cus. As no contraction came on immediately, I retained posses- 
sion of the cavity of the womb,w r hich I gently excited by moving 
my fingers within it, and finally a contraction came on which I 
suffered to push my hand out into the vagina. Upon withdrawing 
the right hand, I felt with the other the womb very firmly con- 
tracted in the low T er belly, and enjoyed the satisfaction of com- 
plete success in this distressing case. 

I have said nothing of the brandy and volatile alkali that were 
given to the woman to keep her from dying. She took a very 



234 INVERSION. 

large quantity of these articles, besides laudanum, before I left her, 
which I was obliged to do in order to attend to another patient; 
and I feel under great obligations to my friend Dr. George Fox, 
who came at my request and took charge of Mrs. S., for the re- 
mainder of the time that she continued ill. Her situation when 
I gave her up to his care was nearly desperate, from anemia; 
nevertheless, by the administration of proper restoratives and the 
judicious exhibition of stimulants during several hours, she, under 
his good and wise care, rallied, and, in no very long time, reco- 
vered a good share of health. 

From that period she was, for a long time, not quite regular as 
to the catamenia, which appeared at uncertain periods, and less 
abundantly than before her dreadful accident. 

Since the above period Mrs. S. has been twice safely delivered 
of healthy children by my friend Dr. Bache. It is worthy of re- 
mark, that the placenta was adherent in these cases also ; and 
that Dr. B. was not able to effect the delivery of the afterbirth 
until he had separated it from the womb by the introduction of 
the hand into its cavity. 

I cannot refrain from mentioning here, the case related by Mr. 
Charles White, of Manchester, in which he succeeded in restoring 
an inverted womb to its natural state by compressing it, and then 
pushing it up. In his case I am not very sure that the inversion 
was complete, since, although he represents the inverted uterus 
to have been as large as a child's head, it was never expelled 
through the external organs, and it is improbable that if fully in- 
verted, it could be retained in the excavation. Mr. W. regards 
his method as of the very highest importance, and thinks he should 
never have succeeded but for the compression of the womb in the 
hands. 

I am ready to admit that it might happen that a tonic contrac- 
tion of an inverted uterus should come on at once, and last so long 
as to prevent the employment of the plan that I suggest; but I 
think it probable that it would always be practicable to return it, 
in any case where it had not been inverted more than four or five 
hours, by waiting for the moment of its greatest relaxation, and 
then first indenting the fundus, and afterwards pushing it steadily 
upwards through the os uteri, and so into the abdomen again. 

M. Colombat, at p. 185, advises that the whole mass should be 
pushed back within the vagina, which is a bad advice, and which 



INVERSION. 235 

I hope you will not follow, but rather follow mine. I made the 
following remarks on Colombat's advice at his 186th page. 

I cannot think that M. Colombat gives the best counsel as to 
the method of proceeding for this reduction. It is hardly neces- 
sary to say that the state of inversion does not deprive the 
womb of its muscularity, and consequently of its ability to suffer 
what are called after-pains. It is also well known that frictions 
upon tjie sur-pubal region, and irritations applied to the mouth of 
the womb, or the internal surface of the organ, are constantly re- 
sorted to as means of exciting its muscular power. It cannot be, 
then, that by M. Colombat's method of grasping the neck of the 
tumor and shoving it upwards, we could fail to excite or irritate 
the organ into a violent exercise of its muscular force, which 
could not exist without hardening the tumor and rendering it stiff 
and inflexible. But if we render it stiff, hard, and inflexible, how 
shall we expect to return it through its hard and rigidly contracted 
os uteri? It is manifest we cannot expect success by so unrea- 
sonable a method of operating. As the ancients used to say, non 
cuivis contigit adire Corinthum, so I may say it does not happen 
to every practitioner to have reduced a completely inverted womb ; 
and the late Prof. Dewees says, at p. 512 of his System of Mid- 
wifery, 2d edit., that "we may justly entertain doubts" of the 
uterus having been reinstated after complete inversion. I have 
already spoken of the case which I saw with the late Prof. 
James and Dr. Geo. Fox, in which the womb was not only com- 
pletely inverted, but had been strongly pulled by the midwife. 
Now in that case, I used the method recommended by Dewees 
and other authors, of grasping the globe firmly with the hands, in 
the view of pushing it back bodily into the pelvis — for it was of 
enormous size, reaching near half way "to the knees — but I was 
unable to meet with the least success, until I had taken off the 
placenta, which still adhered, though detached in certain parts of 
the surface and much torn. And after I had removed the afterbirth, 
I found that the organ became alternately soft and rigid, just as 
happens after delivery in an ordinary labor ; and I further observed 
that to handle it was to irritate its contractility and to harden it, 
which rendered it obdurate against every attempt at reduction. I 
was compelled, therefore, to do what M. Colombat so pointedly 
condemns: i. e., to wait until it became relaxed, and then to in- 
dent the fundus and to drive that cone through the centre of the 



236 INVERSION. 

globe, and up through the cervix and os uteri, until I had carried 
my hand so high that the external organs contained my arm not 
more than four inches below the elbow. I feel very confident 
that if, in any case, I could succeed in indenting a fundus uteri, 
and in bringing the cone up to the os uteri, I could always per- 
fect the operation by gently pressing that cone against the ostium 
uteri, which, under a persevering maintenance of the pressure, 
would yield as readily as it does to a labor pain, or to the cone 
of the hand, when introduced in cases of hourglass contraction 
or spasm of the cervix under encysted or retained placenta. I 
dare recommend to the reader, therefore, to disregard Colombat's 
injunction and to adopt the method which I found successful. 

In any case of irreducible inversion, I suppose all that can be 
done is to have patience, and to hope for the best. 

You should advise the woman to lead the quietest life she can 
afford to lead, avoiding all hard work and all fatiguing and pro- 
tracted effort; advise her to live in hope, inasmuch as though a 
doctor cannot cure the malady, nature can, and sometimes does; 
and as this is one of the greatest occasions for a woman to cry 
out in the language of Terence's Andrian, 

DO ' 

" Juno Lucina, serva me obsecro.*' 

You will be hard pressed to say what are the powers that can 
be employed to bring back to its natural form a womb long in- 
verted. 

In every such case the organ or appendages that are connected 
with the fundus, must be drawn down into the vortex made by 
the total descent of the fundus, and its escape from the circle of 
the os uteri ; that is to say, a good part of each broad ligament, 
of each Fallopian tube, arid of each round ligament. Nor, indeed, 
can it be, that a part of the bladder is not also pulled into the 
vortex. 

When you reflect that the womb inverted, nearly recovers in 
process of time its non-gravid size ; and if so, becomes hard and 
elastic, not ductile, it is exceeding difficult to account for the 
spontaneous reposition. But the law of life, the generic law, is 
so powerful, that the inverted organ must exist under a constant 
tendency at least, to recover its form. At all events, the history 
of our art is sufficiently replete with cases to prove the possibility 
of a spontaneous recovery. I have the less hesitation then in 



INVERSION. 237 

laying before you the following cases, which, I have no doubt, 
are examples of the spontaneous recovery of the inverted womb. 
I take them from Colombat, page 183, where I published them 
as a note in my translation of his valuable work. 

I saw, a few years since, a female in this city, who had been 
the subject of an inversion of the womb for about two years. This 
inversion took place at the time of her confinement, when she had 
a very profuse hemorrhage, so as to be supposed to be in danger of 
a fatal result. Her health gradually improved, but she remained 
subject to frequent attacks of hemorrhage, by which her strength 
became again much reduced. At length, a physician, who was 
called in, detected the existence of inversion of the womb, and 
invited me to examine the case and verify the diagnosis. I found 
the womb projecting into the vagina, and I believe it to have 
been, at the time, completely inverted. It was not much larger 
than the non-gravid womb, bled readily from pressure at the time, 
and was not very sensible to touch, as indeed the healthy uterus 
is not. 

In this case I made the most careful attempt to discriminate 
between polypus and inversio uteri, and I remained under the 
absolute conviction, as did the physician, Dr. Moehring, a highly 
capable practitioner, that the case was one not of polypus, but of 
inversion. I gave such a prognosis as I deemed reasonable, but 
added to it the opinion that she would never again be subject to 
conception. This female was subsequently examined with care 
by Professor Hodge, of the University of Pennsylvania, with the 
same diagnostic result ; and later by Dr. Warrington, of this city, 
well known as a Teacher and practitioner of Obstetrics. These 
gentlemen all agree that the case was one of inversion, and the at- 
tempts made by myself and by them, to reposit the organ were with- 
out the least success. Nevertheless, about some four years poste- 
rior to the period of my visit to her, she became pregnant, and 
miscarried of an embryo of more than three months, under the 
care of Dr. Warrington, who received the embryo, and who feels 
as much surprised as I do at the circumstance. I may take the 
occasion to say that. Dr. Hodge and Dr. Warrington have assured 
me of their convictions of the correctness of their diagnosis in the 
case, and I may add, that I have not the least doubt of its correct- 
ness, for I do not think I or Dr. Moehring could make so gross a 
mistake where our careful attention had been given to the forma- 



238 INVERSION. 

tion of a correct opinion. Far less can I suppose that the other 
gentlemen could be equally mistaken. 

May 5th, 1841. — I saw in company with Dr. Levis, of the city, 
Mrs. S., aged twenty-seven years. She has two children, the 
youngest born five weeks ago. Dr. L. informed me that the child 
was expelled before he reached her dwelling. Upon arriving 
there, he found her lying upon her back, near the edge of the bed, 
the feet resting upon chairs, as if she had hardly found time to get 
upon the bed before the escape of the foetus, which an attendant 
was then holding up in her hands, in order to keep it out of the 
great pool of blood collected about the hips of the patient. The 
child's head, indeed, was quite born before the lady could rise 
from the pot-de-chambre, on which she had placed herself. Dr. L. 
removed the placenta from the vagina, having found the womb 
contracted. 

After the delivery, she flooded a good deal, but, in a fortnight, 
was much recovered. Subsequently to this period, she was again 
seized with flooding of a severe character, since which she has not 
been free from bloody discharges, which are occasionally quite 
copious. Two days ago, the doctor examined his patient, and 
found a tumor projecting from the os uteri, which he suspected 
to depend upon inversion of the organ. She is now very feeble, 
is bleeding, and has frequent fits of hysterical delirium. 

Upon Touching per vaginam, and upon inquiry made by means 
of the speculum, and even by disparting the labia with two fin- 
gers of each hand, it was easy to discover a tumor which bore so 
great a resemblance to an uterine polypus, that it was difficult, 
viewing its size, form, color and resistance, to believe that it was 
not a polypus which had existed throughout the gestation ; an 
idea which yet could not be very reasonably indulged, seeing she 
had gone through a healthful pregnancy to full term; though I 
admit its possibility in certain cases. As the parts, as well as 
her whole frame, were very much relaxed, I introduced half of my 
right hand into the vagina, behind the tumor, so as to enable me 
to carry two fingers quite far up into the cul-de-sac, behind the 
cervix uteri, which was not inverted. Having thus # possession of 
the canal, I carried the two fingers forcibly upwards and forwards, 
so near to the margin of the superior strait, just behind the sym- 
physis pubis, that the fingers of my left hand, pressed forcibly 
upon the lower part of the hypogastrium, were but a very small 



INVERSION. 239 

distance from those of the right hand within the vagina. The ends 
of my fingers approached so near to each other That I remained per- 
fectly convinced that no womb was interposed betwixt them, and 
that the tumor within the vagina consisted of the inverted womb, 
and nothing else. She remained for some time feeble, and subject 
to hemorrhage, which gradually disappeared. She made a journey 
to one of the Western States, and returned to the city : since w T hich 
she became pregnant and gave birth to a child. 

Now, in these two cases, I am very confident of my diagnosis; 
and, as both these women have since been the subjects of concep- 
tion and pregnancy, without artificial reposition of the organ, I rest 
convinced that the inverted womb, where the accident does not 
prove suddenly mortal by hemorrhage, nor slowly fatal from ex- 
haustion by inflammation and gangrene, or discharges, may re- 
posit itself in some rare instances. I made a statement of these 
cases to Dr. J. Greene Crosse, of Norwich, England, to whom the 
profession is about to be indebted for a second part of his work 
upon inversion of the womb, which I impatiently expect. I draw 
from my experience in these cases, and from what is stated by M. 
Colombat, much consolation for those women who are so unhappy 
as to be affected with ' inversion of the womb, irreducible by 
manual aid. 

I think these cases are well calculated to encourage and 
strengthen your hands in the administration of your art, for those 
persons who, having suffered inversio uteri, cannot be relieved by 
the chirurgical reposition of the womb. They hold out consider- 
able encouragement for cases otherwise hopeless perhaps. As to 
the losses of blood that ensue immediately after the accident of 
inversion, you will have little to fear, provided your patient es- 
capes the foudroyant hemorrhage, and be allowed to live long 
enough to get her womb once well reduced to near the non-gravid 
dimensions. By rest, by styptics, by position, &c, you will be 
enabled to bring her into a state of comparetive security and com- 
fort; and if you keep the inverted womb quite high up within the 
pelvis, she will always have the hope, at least, of one of those 
spontaneous recoveries. Surely, you would not indulge the hope 
of such a recovery, should you allow the inverted globe to pass 
forth and remain outside of the genital fissure. 

If in such a case, you should be unable to make the woman 
bear a pessary, you could, at least, invent a pad and T bandage. 



240 INVERSION. 

which, compressing the labia together, would effectually obviate 
the procidentia of the ruined womb. 

I confess, my young friends, that I am deeply interested in the 
question, as to whether an inverted uterus can be reposited by an 
intrinsic force of the body. I was, upon first publishing the above 
cases of spontaneous recovery, much concerned lest the brethren 
w T ho should read the account of them, might accuse me of credu- 
lousness in supposing such a thing possible. But the records of the 
science are not without strong proofs of the possibility of such 
spontaneous recovery. 

Daillez, who published certain lectures of his master, the great 
Baudelocque, gives accounts of two such cases seen by that illus- 
trious physician. I am not able to quote from Daillez himself, 
whose essay was published in the Theses des Paris, which I have 
not been able to procure. It is cited by Mr. Crosse; and also by 
Messrs. Paul Dubois and Desormeau, in their article in the 30th 
vol. of the Diet, de Medecine, p. 358. These are their words : 

"The womb, after having been long inverted, has been found 
spontaneously to recover its natural state, in consequence of some 
violent accidental shock suffered by the woman. It seems that 
the spontaneous reduction of the uterus took place after two 
months' duration of the accident in one of the cases reported by 
Leroux, as appears from a letter to Louis, mentioned in Daillez's 
Dissertation, before-mentioned. The same dissertation also con- 
tains two cases, one by a surgeon named Barre, and the other by 
Baudelocque ; in the first, the reduction occurred at eight months, 
and in the second, after the lapse of eight years. In cases of in- 
version caused by uterine polypus, there is no special indication of 
treatment, since the womb recovers its proper form as soon as it 
is freed from the weight that has dragged it down." Such is the 
statement by Dubois and Desormeau. 

As to the operations for the removal of the incurable and in- 
supportable inversio uteri, I refer you to Mr. Crosse, and to 
Colombat. 

I am very truly your obedient servant, C. D. M. 



POLYPUS. 241 



LETTER XIX. 

POLYPUS UTERI. 

Gentlemen: — Before proceeding to my remarks on polypus, 
allow me to premise an account of a case of Inversion, that of 
right belongs to the last letter, but which, having been accidentally 
omitted, I shall relate here. It is a case of inversion of the womb, 
related by Dr. Thos. F. Betton, of Germantown. I desire you 
carefully to read it, in order that you may more fully appreciate 
the danger to which a woman is exposed by such an accident. 
You will see that Dr. Betton took, upon his arrival, all the pos- 
sible precautions against the danger; but the loss of eighty 
ounces of blood had so exhausted the vessels of the unfortunate 
woman, that it was impossible, even by Dr. B.'s judicious, 
prompt, and scientific course, to rescue her from the conse- 
quences of the accident. The case was originally published in 
the Am. Journ. of the Med. Sci., for 1826, vol. 19. 

Dr. Betton says, " On the evening of the 4th of August, 1836, 

I was called to see the wife of S. B , living at the Rising Sun 

Village, about three miles distant. On reaching the house, I 
found a woman of about 18 years of age, in extremis. The mid- 
wife gave me the following history. The patient had had an 
easy delivery : the midwife placed her hand upon the abdomen, 
to feel if the uterus were contracted, but could not perceive it. 
A violent pain followed immediately, and the placenta, with 
something adhering to it she did not understand, was forcibly 
expelled. This, I found on examination, to be the uterus, com- 
pletely inverted and prolapsed, lying like a gum elastic bottle, 
between the thighs. 1 immediately separated the placenta, and 
endeavored to restore the uterus, which endeavor was successful 
in two or three minutes. The woman was pulseless, from loss 
of blood; the carotids could not be felt, and the action of the 
heart w r as extremely feeble; jactitation extreme; mind wander- 
ing. About twenty ounces of blood had coagulated around the 
uterus, and between it and the placenta, which was partially 
16 



242 polypus. 

separated. From the distance at which she lived, I did not see 
her for at least one hour after the occurrence of the accident, and 
she had lost full eighty ounces of blood before my arrival. She 
did not lose more than two or three ounces after the reduction of 
the uterus, but in her exhausted state, that wastoo much. I gave 
her immediately a large dose of the vin. sec. corn., but it failed 
in producing any effect. Brandy, and wine and water, were 
freely administered, but in three-quarters of an hour after my first 
seeing her, she expired. 

"My own conviction always has been, although the midwife 
denied it at the time, that she had produced the inversion and pro- 
lapsus, by pulling too strongly at the cord." 

Let us now proceed to our inquiries upon polypus of the womb ; 
and I ask, is it not obvious that all the tissues of a living body 
are undergoing a perpetual accretion and waste ? that the perfect 
balance between this deposit and absorption, maintains all the 
organs and the parts, and the whole body in one even tenor of 
health, of weight, and dimensions, for months and years of time; 
and that the loss of such a balance or equableness of the waste 
and deposit, changes the weight and dimensions, as well as the 
health of the body, or of any of the parts or organs of it? But, 
when the accretions of a part become excessive, then we have 
either a hypertrophy or a tumor. 

It is one of the standing miracles of nature, that the bodies of 
creatures are maintained at pne even tenor, not only through the 
lifetime of the particular individual, but from age to age. Thus 
a single herring shall develop 300,000 eggs, from each of which 
shall be evolved a herring, whose weight in no instance, perhaps, 
in the countless myriads of that tribe, will ever be found to ex- 
ceed by 200 per cent., the weight of a perfect fish of its genus 
Clupea. 

On the other hand, an army of wild pigeons so numerous as to 
darken the air for days and days of its migratory flight, will not 
contain a single bird as large as the barn-door fowl; because 
each genus of creatures, by its miraculous generic law, is limited 
to a certain stature, weight, and dimensions. 

The same thing is true of the vegetable tribes. You shall 
never expect to see an arbutus rival the forest oak, nor a violet 
to grow on the branches of a trunk as tall as the plane tree. You 
wonder not, nor become amazed at this miraculous order; but 



polypus. 243 

you and all your County would turn out in crowds to see an ear of 
Indian corn growing on a wheat stalk, or a magnolia grandiflora 
blossoming on the tender vine of a cucumber. You are, there- 
fore, not surprised at the daily miracle set before your eyes in the 
order and regularity of Nature's operations; but you are startled, 
and lift up your hands in a gesture of wonderment, when she 
errs, and in her errors gives rise to some unnatural form or con- 
junction ; some Saeculum Pyrrhse, nova monstra qusestae. Do you 
not perceive in this statement reasons to be far more surprised, 
when you observe that men and women too, are found to live out 
their threescore years and ten, and even longer, without having 
experienced during their whole life, a single deviation from the 
natural forms and weights of their organs, or of their external 
configuration ? 

There can never be deposited in an organ, any atom or mole- 
culus of its constituent tissue, but by an act of a blood-vessel; 
which puts it down in its place, and puts down the true chemical 
elements in the right place. But the blood-vessel that carries and 
deposits the moleculus, can only deposit it under the indicating 
and controlling force of the accompanying nerve. You are very 
well aware that each organ has its own nutritious artery to con- 
vey to it the materials for its daily accretion; that it has its lym- 
phatic absorbent, to remove the daily detritus of the life of the 
organ ; and also its generic nerve which indicates and controls by 
its force, the kind, as well as the amount of the daily deposit, and 
the kind and amount of the daily absorption. 

You do not doubt if the generic nerve becomes compressed, or 
is tied or cut off — or softened, that the organ will waste away, or 
become atrophied, however sound and perfect the artery may re- 
main ; or if too energetic in its indication and compulsion of the 
daily deposit, that the organ may become hypertrophied, from a 
faulty rate of action of the generic nerve. 

In the womb, for example, the daily detritus and accretions of 
life will maintain the form, consistence, and weight of that body 
in one even tenor, for a lifetime, if it continue obedient to the 
generic law of its development — for that law which tends to keep 
it always two inches long, and of the weight of two ounces, and 
of a certain form, is as truly a generic law for the womb, as is 
the law that commands the genus Bos, or Equus for those genera. 
But, if it disobey its generic law ! What then ? 



244 polypus. 

Now in the code of morals — the Decalogue — we have plainly 
set down for our guidance, certain rules, or laws of action, to be 
obedient to which, or to be disobedient to which, constitutes us 
good or bad men, righteous or sinners. 

So, in the physical nature of living beings, there is a law which 
they ought to obey, and be bound by; if they disobey! if they 
fail to be governed by the provisions ordained for their just 
maintenance! then they may be likened to sinners against the 
moral law. They, in fact, do sin, rebel against, or contemn the 
law ordained for their government, their protection, and security. 
In this physical disobedience, I can perceive a close analogy with 
moral disobedience. In each, it is the first step that is fatal — 
c'est le premier pas qui coute. In the moral law, the first sin, or 
corruption, leads to still renewed wickedness, until the whole 
moral constitution of the man is subverted, changed and ruined, 
and becomes a mass of moral pollution. So, in the physical, or 
organic sin ; the first error is followed by the second, until the en- 
tire constitution of the organ is subverted and ruined so completely, 
so completely changed, that the most expert anatomist can no 
longer detect its old familiar features in the depraved and hetero- 
logue mass that lies under his scalpel and his doublet. 

In the hopeless wreck of the moral creature, brought about by 
vicious indulgence, the voice of conscience is raised in vain, the 
appeal of reason is powerless ; the invitation of the minister of 
the Gospel is like the idle wind, and suasion and argument 
equally fail to recall him to the path of duty and safety. Just so is 
it in the physical sin of the organs ; when they have fairly broken 
the generic law, they continue free from all future bonds, and go, 
like the idle wind, where they list, and no one knows whither. It 
is in vain that you apply the restraints of your hygienic and thera- 
peutic forces. The heterologue mass has no generic law, and the 
cry of the rest of the organs that suffer for its rebellion, like the cry 
of society against the breaker of the law, is raised for ears that 
are deaf. Such an organ is become like a wild horse in a bound- 
less plain, that scorns the caress; and, fleeter than the winds, will 
not bend his neck to the accustomed rein. 

I have been led into these reflections, by having witnessed to- 
day, June 10th, the dissection of a preparation brought into the 
city, by two medical gentlemen from a distant county. Prof. 
Horner made the examination. The whole mass weighed thirty 



polypus. 245 

pounds, and consisted of a womb, very much thinned and at- 
tenuated, which, upon being laid open by an incision from the 
fundus to the os uteri, disclosed a solid tumor, whose weight 
could not have been less than twenty-nine pounds avoirdupois. 
This solid mass was a fibrous polypus, springing apparently from 
the side, not the fundus of the uterus; and attached here and 
there by strong exudation or accidental attachments — the results 
of pressure and inflammation long endured. 

Now, this vast mass probably sprung, at the beginning, from 
the very slightest aberration of the development force. The 
offence was small, and then became greater, until, in the end, you 
see how " rank" it was. What therapeutical power could you 
bring to bear as a control upon such a heterologue mass as this 
polypus of twenty-nine pounds avoirdupois; a polypus, whose 
sole connection with the living constitution of the poor victim it 
destroyed, may have been by a root, neck, or pedicel, not bigger 
than your thumb ? 

Don't you see what a physical sinner it was, and how small 
was its first offence ? It had broken its generic law, and you 
perceive the end. 

Let us take good heed, that in our small and venial offences, 
we do not come to say with the king, " Oh, my offence is rank; 
it smells to heaven!" 

This parallel between the moral and physical states of disobe- 
dience to the laws that ought to govern both, I have run in 
order that I might haply impress your minds, and my own also, 
with clearer perceptions of what we have to hope, and what we 
have to fear, in the conduct of those maladies that are, in the 
strictest sense of the term, chirurgical. I also hope that the ana- 
logy I have set forth, may be not without some advantage in its 
moral, since from it we may lay to heart the equal necessity in 
morals and physics, of opposing the very beginnings of evil ; 
and since we ought, like Jacques in the forest, to be able to find 
" sermons in stones, books in the running brooks, and good in 
everything." 

But let us leave moralizing, and return to our physic; all 
the cavities of the living body, as the cavity of the nostrils, the 
ventricles of the brain, the womb, and even some of the solid 
parts are liable to become the seats of excrescence or growths, 
some of which take the name of polypus, which is a tumor grow- 



246 polypus. 

ing by a narrow neck, or root, out of any superficies, and extend- 
ing itself in length and breadth, to an extent limited only by the 
duration of the life of the patient, and by accidental strangulation, 
or death taking place in the tumor itself. 

Such a tumor is a polypus, which may be either hard or soft, 
being called in the former case a fibrous, and in the latter a cel- 
lular or cellulo-vascular polypus. Such a tumor possesses a low 
organic life. It has a very traceable interior circulation, while its 
superficial circulation is in many cases active enough to give rise 
to profuse hemorrhage : without some internal circulation it would 
be subject to decomposition ; without an active superficial circula- 
tion, it would not grow. Its growth is supposed to be peripheral. 

A polypus of the womb is far from being a rare chirurgical 
malady. A polypus growing from the interior of the uterus, may 
be supposed to be, in its earliest state, a small excrescence like a 
papula, which, rising higher and becoming broader at the base for 
a certain space of time, ceases at length to grow at the base in 
breadth, but elongates itself, spreads out into an utero-morphous 
shape, filling the cavity of the organ more and more as it grows 
larger and larger, sometimes distending the uterus enormously, as 
in the instance above mentioned, and in other instances pressing 
itself into the canal of the cervix uteri, and so dilating it as to find 
its way at last through the os tincse, whence it slowly advances 
into the vagina, expanding in a lateral direction, so as, at length 
greatly to distend that organ. 

A polypus, then, is a tumor either fibrous or cellular, that is, 
either hard or soft, springing by a narrow neck or stalk from the 
womb, and increasing in size daily, so as to distend and fill up 
the womb to a considerable size : or otherwise, it may dilate the 
neck and mouth of the womb, so as soon to come forth into the 
vagina, or even to project beyond the ostium vaginae. 

A polypus will not, in all cases, come out of the womb ; espe- 
cially will it not come forth to disclose its true nature, in those 
cases where accidental adhesions have taken place between it and 
the womb. In such a case of adhesions, it would be in vain that 
the womb should make efforts to cast out the incumbrance; no 
pain nor contraction could get it forth from a cavity to which it 
has become bound in consequence of adhesive inflammation. In 
all cases, however, where the sole connection of the polypus and 
womb is to be found at the root or neck of the polypus, we have 



polypus. 247 

reason to expect, in the long run, that the uterus will become 
irritated into contractile or labor-pains, and cast it out, just as it 
does cast out a dead ovum or embryo that has perished in the 
early months of pregnancy. 

It is very possible, that the earliest beginnings of a uterine 
polypus may consist merely in a hypertrophy of some superficial 
layer of the womb, and that the tumor, in this sense, is a part, 
and a real part of the womb itself, partaking of the true nature of 
the uterine tissue: but, if the growth proceeds, so as to make it 
come to be either a fibrous or a cellular polypus, it cannot be sup- 
posed that it will go very far, before the new accretion will be- 
come really heterologue, and thus give rise to a mass growing 
from the uterine surface, nourished by branches of the uterine or 
spermatic artery, and yet retaining, in its histological character, 
no true features of the womb from whence it derived its origin. 

Such a tumor has no generical limit ; it might grow to the 
weight of a ton, could it be supposed to continue in the reception 
of its pabulum from the uterine branches to which it owes its ex- 
istence. It has no generic delimitary term ; and it can have none ; 
seeing that it carries with it no special absorbing apparatus to 
counteract the accretive power which it receives from the vessel 
that makes the deposit and from its nerve. It is probable, as I 
before said, that most of the increase which it receives is derived 
from the exterior surface of the tumor, which, even in the most 
enormous tumors of the womb, it is said, may be successfully 
injected upon the more superficial portions. Dr. Th. SafFord Lee 
tells you at p. 8 of his book on Tumors of the Uterus, that an 
injection may be made to penetrate " the morbid mass," and 
that 2268, 2270, and 2266, in Guy's Hospital, are cases in 
which the injection has been made; but surely Dr. L. would not 
suppose that such a tumor as he has beautifully figured in fig. 2 of 
his plate, could possibly be injected by the anatomist; at least not 
the whole of it. 

Such a tumor carries with it in its augmentation, delicate pro- 
longations of the arterioles and capillaries, from which it draws 
the material of its daily accretions. It probably also carries with 
it a certain amount or form of nerve fibrils, without the presence 
of which it would be subject to putrefaction; but those nerve 
fibrils may reasonably be deemed to be imperfect in their action, 
and as serving merely to retain the growing mass in vital relation 



248 polypus. 

to the body of the woman, yet unable to control or modify the ac- 
cretions as they can and do in a healthy normal function of the 
development forces. I deem that there cannot be truly any life 
where there is no cerebral or nerve matter ; but I can well conceive 
that, in the case of the most extreme deviations as to form, magni- 
tude, and consistence of organs or parts, by their conversion into 
tumors, there must accompany them portions of nerve matter, de- 
riving a source from the nervous system of the patient, yet so 
imperfectly connected with it by constitution or power, as to lose 
the faculty of controlling the development of such said organ or 
parts. 

If this view of the case be just, it would be idle to attempt to 
modify or control the growth of such a tumor, by means of drugs 
and medicines administered internally. Since, however power- 
fully such drugs and medicines might be able to modify the 
actions of the woman's constitution under its natural physio- 
logical laws, they could not reach in their influence, nor in any 
degree control the accretion forces employed in the production of 
the polypus, which, being heterologue, will not, neither indeed 
can, come under obedience to the physiological law of the woman's 
life ; a law with which it has no longer any lot or part, beyond that 
of living as long as she lives, preying as a parasite upon her ma- 
terials, and sending back no answering organic influences to 
serve in maintaining that beautiful harmony of the organisms, 
whose concert of action is life. Such a growth is not a part or 
parcel of the economy; it is not like one of the members of a 
family or a flock, but is like a stranger or a thief and a robber, 
that has entered in by guile or by violence, to dwell among them 
and to disturb and destroy them. 

Hence you see, that such tumors are to be treated chirurgically 
and not medically. They may be extirpated, they cannot be 
cured. Save yourselves and your patients, therefore, the trouble 
and loss of using physic or drugs. 

In a womb that becomes the seat of a polypus, it is natural to 
expect the signs of uterine irritation. Therefore, as soon as the 
excrescence begins to acquire a certain volume, and to press upon 
and dispart the cavity of the organ, we may expect to find the fruits 
of such irritation, in diseased sensations, as pain, weight, tension, 
modification of the menstrua, white and sanguine discharges, &c. 
It is true, that we shall not be able in the early stages, to make the 



polypus. 249 

diagnosis of such a tumor, because, when it inhabits the cavity of 
the womb, and expands that portion of the organ only, it may not 
in the least degree change the form and dimensions or resistance 
of the cervix. We have no art and no skill, under such a state of 
things, to pronounce confidently as to the existence of a tumor; 
though we may be induced to infer it from the total absence of 
signs of other malady. It is inaccessible to our touch or sense. 

A woman otherwise in good health, shall at irregular periods 
be attacked with uterine hemorrhage, whether moderate or violent, 
and you come to make your diagnosis and can by no means dis- 
cover that there is any inflammation, ulceration, deviation, hyper- 
trophy, plethora, &c, on which to rely as sufficient cause for the 
irregular and alarming attacks of flooding. 

You are fully resolved that it is not a menstrual hemorrhage, for 
the causes of menstruation are not so irregular in their operation, 
as to allow you to call it mensual hemorrhage : what course will 
you take to clear up the difficulty? I see not what other recourse 
there is, besides that of accusing a polypus of the womb. The 
womb-sound or womb-probe, will not, I think, throw any very 
clear light upon the case for you. The vaginal taxis and the hy- 
pogastric exploration, cannot clear up your difficulty. It is a 
process of ratiocination that leads you to the one and only possi- 
ble conclusion. The case is one of a polypus, because it could 
be nothing else. 

I have not been afraid to make such a diagnosis. I had for ten 
years the care of a female, who at the age of about thirty years, 
was repeatedly attacked with the most alarming uterine hemor- 
rhage, accompanied with severe pelvic and hypogastric pains. 
I do not suppose I have ever met with more violent hemorrhages 
of the womb than in the person alluded to. It seemed scarcely 
credible that she could survive the attacks. She was very thin, 
and feeble, and pale and rachitic. I never could detect any aug- 
mentation of the size of the fundus and body of the womb by the 
Touch, or by external palpation, and yet so free was she from all 
the symptoms of other disorders of the interior of the womb, that I 
ventured to tell her she had polypus, which at some future day 
would surely disclose itself. 

I was called in the course of consecutive years, many times to 
this person, on account of the frightful hemorrhage and pain with 
which she was attacked; and I repeatedly explored the case by 



250 POLYPUS. 

the vaginal and rectal Touch and the hypogastric palpation. I 
could never detect any certain physical signs of the malady, but 
rested convinced that the polypus was concealed within the womb. 
At length, amidst the severest pelvic pain and a great flooding, 
the polypus was expelled into the vagina, and I removed it with 
Dr. Gooch's double canula. After. which she had no more re- 
turn of the hemorrhage. But she died two years later, with pul- 
monary consumption, connected with a distressing rachitis, and 
precipitated, I suppose, by the extreme debility brought on by 
ten years of repeated hemorrhages. Life had become a burden 
to her, and she died with a countenance beaming with smiles, as 
she faintly repeated, in broken and scarce audible whispers, the 
beautiful verses — 

Vital spark of heavenly flame ! 
Quit, oh! quit, this mortal frame; 
Trembling, hoping, lingering, flying, 
Oh, the pain, the bliss of dying; 
Cease, fond nature, cease thy strife, 
And let me languish into life. 

Do you ask me why, in a letter on Diseases of Females, I cite 
these mal-a-propos memoranda of a death-bed ; and which have 
nothing to do with our subject? I answer that my letters are 
about females, as well as their diseases and remedies. I would not 
forego this opportunity connected with her case, to make mention 
of one unknown, humble, truly pious, whose gracious manners, 
whose noble sentiments, and heaven-tempered spirit, as well as 
her willing submission to an inevitable and painful fate, filled me 
with admiration of the characteristics of woman. I have seen a 
man die with the dignity of a Christian and a gentleman; none 
but a woman could die with such gentle and feminine grace and 
beauty as poor Anne Ryder. In her, her nature was wholly un- 
changed, until the last dull clogs of her mortality were already 
cast off. 

There is nothing so difficult, my dear young friends, as to be- 
come a physician from the reading of mere descriptions of disease 
in the books. To read those descriptions is well, is indispensable. 
But to understand them, one must see the cases, and compare 
them with the book description. I can hardly flatter myself, that 
I shall be peculiarly successful in teaching you how to discrimi- 
nate between the different maladies that are often characterized 
by the same outward signs. Let me hope, however, that I can 



POLYPUS. 251 

describe a case and a conversation that I had some time ago, with 
a patient; and we shall see whether I can give you a clearer view 
than you now have, of the method of proceeding, and of the ration- 
ale of an opinion, that you may readily form without greatly vex- 
ing your patient. 

The person in question w T as a very tall, slender woman, a widow, 
who lived in Sugar alley, near Seventh street; she may have been 
some thirty-eight years of age, and had children. 

When I went to her chamber, she sat at an open window sew- 
ing the leather binding on a truss, which was her Trade or occu- 
pation. The room was about fifteen feet square; and I seated 
myself near the door, while she sat at the window, say, fifteen or 
sixteen feet ofT. She was a stranger to me, and I said, 

"You wished to see me as to your health?" 

" Yes, doctor, I have been long sick, and knowing that you at- 
tend many women, I was in hopes you could tell me what's the 
matter." 

"Why, you look very pale; too pale and weak to work, I should 
say. Pray how long have you been so?" 

"Oh, a long time, sir." 

"What makes you so pale, though?" 

"I am all the time unwell." 

"I should think so. How long have you been unwellV 

"Six years and a half." 

"Six years and a half! Do you mean really to say six years 
and a half?" 

"Yes, sir. I have not been free from my courses for six years 
and a half." 

"What! not one day?" 

"No; not one day." 

" Tell me; are you serious, when you say that for six years and 
a half you have not been a single day without an issue of blood?" 

"Yes, sir, perfectly serious; I have not passed a day without a 
show, and sometimes a flooding, for six years and a half." 

"But that is enormous; yet to look at your face and hands, 
and to see how pale you are, one might well believe it." 

" It is perfectly true." 

" Have you any pain ?" 

"No, only weakness." 

" No pain in your back, or in the lower part of the bowels ; or 
thighs?" 



252 polypus. 

" Not the least; only weak." 

"No offensive discharge?" 

"No, sir." 

"No burning sensation, no shooting pain within, and between 
the two hips?" 

"Not the least." 

" Are you much unwell still?" 

" Sometimes very much — sometimes not much — but I'm never 
without it." 

"Any trouble about making water?" 

"No, sir." 

" No pain at the stool? no difficulty?" 

"Never." 

"And you have no offensive discharges?" 

"None." 

" Then you have a polypus of the womb." 

"What is that?" 

" It is a tumor, or lump that grows in the womb ; it has a nar- 
row neck, which lets it hang out of the womb into the passage ; 
it has blood-vessels, that always bleed." 

" What causes it?" 

" I'm sure I don't know. Nobody knows ; it comes without 
any ascertainable cause ; it comes in women who bear children, 
and in those that have never had any, as well as in unmarried 
women." 

"What can be done for it?" 

"It can be removed with a ligature; that is, by tying a string 
round its neck, whereupon it will fall off, and then you will bleed 
no more; but, if you do not lose your blood, you will grow strong 
and healthy again." 

" But I cannot let you do it." 

"You ought to have it done ; at least you ought to have it ex- 
amined, for, though I am very sure of rinding the polypus, I have 
never yet had any sensible sign of it. I only judge it to be 
there." 

"I cannot." 

"Very well, madam. You have bled six years and a half ; 
you are greatly reduced; your blood is thin as water, and if you 
go on much longer, there is fear you w 7 ill have a dropsy, and then 
lose your life. Would that be wise, or foolish ?" 



polypus. 253 

"I can't help it; I cannot think of being examined." 

" Very well; it is your affair, not mine. I have no other ad- 
vice for the present, than that you should carefully revolve the 
prospect before you, and if you should change your mind, you 
can let me know, if you should desire to see me." 

And so I left her to her reflections. On the next day she 
begged me to return. I went to her, taking my Gooch's canula 
with me, and found a soft polypus, large as an egg, on the neck 
of which I threw Gooch's ligature, and the tumor fell off in less 
than twenty-four hours ; after which she had no more hemorrhage, 
but recovered her health and strength. 

Now the above is, I think, very near literally the conversation 

I had with Mrs. , and since you have read it, I ask you what 

other opinion I could possibly take up as. to her case? 

She had no pain; therefore she could have no carcinoma; she 
had no disagreeable odor of the discharge ; a fortiori, she could 
not have cancer ; she had been unwell six years and a half with- 
out a day's intermission; but that was not the character of a men- 
orrhagia. It must be that she had some insensible tumor that 
would bleed always, and yet never give her any pain ; what in- 
sensible tumor? There is none other than polypus uteri. Had I 
not, therefore, a just ground to make the inferential diagnosis of 
polypus uteri, and to indicate the proper treatment? 

What a shameful mistake to have said — it is change of life — it 
is weakness — it is irritation — it is this, or it is that, and so compel 
the woman to swallow drugs, usque lid nauseam, and at last find 
one's diagnosis proved erroneous to the discredit of Medicine, 
which is always discredited by the mistakes of physicians. 

A polypus of the womb, I have said, cannot come out from its 
nidus, provided it have become attached at various points to the 
uterine walls, by inflammatory adhesion. You are not to be sur- 
prised that such adhesions do occur, for as the superficies of the 
polypus is quite vascular, and covered by a smooth membrane, 
which is probably of the nature of mucous membrane, adhesions 
would be very likely to ensue upon the escape of exudation par- 
ticles from the uterine, or from the polypous surface. 

I have no hope to offer for such cases. It seems to me in vain 
that any one should attempt to extirpate, and I have no faith in 
the curative power of drugs for them. 

I am unable to state what is the difference of the causes that on 



254 polypus. 

the one hand produce fibrous, and on the other cellular, or soft 
polypus. I believe they are equally curable by the ligature ; at 
least, I have not met with any instance in which, after the remo- 
val by the ligature, the tumor has again proved troublesome by 
renewed development from the root ; which is not a little wonder- 
ful, seeing that, whenever we destroy one by the ligature, we 
must leave the base or root from which spring all the vessels and 
other apparatus concerned in the nutrition and development of 
the tumor ; and that might well grow again. 

I have met with no case in which I could accuse the polypus 
of malignant degeneration, except one that I saw in the Lying-in 
ward of the Penna. Hospital; and that, perhaps, was not a true 
polypus in its origin. It was the case of a stout, short woman, 
about fifty years of age, who had long had putrid sanious dis- 
charge from the womb, and in whom, after a long time, the os 
uteri opened sufficiently to admit of the introduction of two fin- 
gers, by which a mass occupying the cavity of the organ could 
be felt. I in vain attempted to pass an instrument containing a 
ligature, and was obliged at length to break the mass with the 
fingers, by means of which I got away a large handful of hetero- 
logue material, half fibrous, half cerebriform, to the considerable 
relief of the patient, who at subsequent times was relieved in the 
same way, of considerable portions of the same kind, as the con- 
tractions of the womb forced them down within the reach of the 
fingers. But, although a considerable quantity of it was brought 
away, the production of it continued. The woman left the ward 
at length a good deal relieved, as it was thought, but it proved 
otherwise in the end. Her sufferings became very great, with 
all the marks of malignant degeneration of the uterus. 

I know that Dr. Dewees attended a lady here many years ago, 
affected with polypus uteri : he removed the polypus, as he in- 
formed me, and unmasked a cancer of the cervix, which soon 
afterwards destroyed the patient. 

You will find in your studies, that it is conceded the presence 
of a uterine polypus may lead to malignant disease of the womb. 
The same thing happens in polypus of the nose, or antrum. 
The distending pressure of the tumor alters all the tissues that are 
in contact with it. The same might be true of the uterus and 
vagina. 



polypus. 255 

There are various instruments for putting the ligature on the 
neck of a polypus. 

I prefer Gooch's to all of them ; and I think the ligature is to 
be preferred to all other modes of extirpation. It is not in every 
case to be effected without hemorrhage. I know of two cases 
here, in which the hemorrhage was terrible ; but there is less 
danger from hemorrhage by this process, than by that of twisting 
or avulsion of the tumor. 

Whenever you are called to a case of polypus uteri, in which 
'the neck of the tumor can be secured by a ligature, it will be your 
duty to put it on. You might be able to put it on in certain of 
the cases even where the tumor is still contained wholly in the 
womb ; but, in order to such a great success, it will be indispensable 
that the os and cervix uteri shall be both dilated and dilatable ; and 
the polypus ought not to be a very large one. "Where the polypus 
is of vast size, an instrument used to conduct the ligature upon its 
neck, should be so curved, as to fit the convexity of the tumor, 
and the coincident concavity of the womb. It must be a very 
difficult task to arrange the curve in a proper way ; and if it be 
not so arranged, the pressure of the instrument could not but be 
very dangerous; since the inner wall of the uterus is ill calcu- 
lated to suffer the forcible contact of any foreign body long con- 
tinued. Upon the whole, then, I am disposed to advise you, 
where the polypus is still within the uterine cavity, to wait until 
it is forced into the vagina, where there is little difficulty, and per- 
haps no danger attending the operation of tying it. 

Dr. Lee, On Tumors of the Uterus, p. 69, says, in speaking of 
the treatment of polypus, "Supposing it to be placed within the 
cavity of the uterus and the os uteri closed, it would be folly to 
attempt its removal; we must suppress the bleedings by plugging 
the vagina, rest, an elevated position of the pelvis, and local cold, 
with some refrigerant drink." 

I am glad to be able to quote so sensible a writer in behalf of 
so sensible an injunction ; for there are cases of persevering en- 
deavors to extract large polypi from the womb, that bespeak more 
obstinacy than prudence on the part of the practitioner. 

The rule is a good one, not to attempt the extraction until the 
tumor has passed into the vagina. I do not mean by this to say it is 
not to be done until the whole tumor has come down, but only that 
we should wait until it is so far descended that the uterine cavity 



256 polypus. 

which still contains a part of the mass shall have become a cylin- 
drical, and not a globular or pyriform cavity; whenever it has 
become cylindrical, which will be the case where the major part 
of the polypus is pushed out, no objection can exist against the 
casting of the ligature upon it. 

To adjust the ligature upon the polypus even in the vagina, is 
often a vexatious and difficult task. Take patience for the work, 
and be not in a hurry to get it done. If the vaginal walls are 
tense, you will require some time. 

Let the patient lie upon her back; the hips to the very edge of* 
the bed ; the feet resting on the backs of two chairs, well sepa- 
rated. 

Let the Gooch canula be of a good length — most of them are 
inconveniently short. See that the ligature is long enough not to 
annoy you with the tubes interfering with your hands. See that 
the ligature be well oiled, so that it may run freely ; strong enough 
not to cut or break; and small enough to move freely in the 
canula. 

Arrange the canulse so as to have them parallel in the right hand, 
introduce them parallel, to the greatest depth ; and then taking one 
in the left hand, while the other is held in the right, carry either 
the right or the left hand one round the tumor, until you bring it 
parallel again with its fellow. In this way you will have cast 
the ligature round the neck of the tumor; next, you are to slip the 
canulse each into its ring at the end of the staff, and slide that ring 
to the top, securing the foot of each canula in its cannon. If 
great care be not taken in doing this, the ligature will be apt to 
fall off. You will know whether you have succeeded, upon gradu- 
ally tightening the cord. If it has taken proper hold, it will pull 
the polypus downwards when you draw with it. Take great care 
to slide the ends up as far as possible, so as to get as much as you 
can of the base or neck of the tumor in the loop, and then draw 
it as tight as possible, so as effectually to strangulate the mass. 
If the polypus be a cellular one, you may expect it to fall off in 
twenty-four or forty-eight hours ; if it be a hard fibrous one, it 
sometimes requires seven or eight days to cut through. 

The woman ought to be put to bed, and commanded to keep 
her bed, until the canula comes away. 

Once a day the ligature should be tightened, as the compres- 
sion is lessened by the daily shrinking of the mass. 



polypus. 257 

As soon as the mass dies, a most foul and offensive discharge 
comes on, which requires all the cares of cleanliness. Sometimes, 
when the apartment is warm, copious injections of soap andw^ater 
should be made with a syringe having a gum elastic tube adapted 
to the metallic fistula. 

If the polypus is very large, you can pull it away with a Mu- 
zeux forceps, or with a sharp crotchet, or even with the obstetric 
forceps. 

In some cases, the tumor has been so large as to require to be 
divided before it could be got away, by a polypotomy operation, 
as one might call it. 

The extirpation of a uterine polypus is a very beneficent ope- 
ration, as it relieves the patient from wasting hemorrhage, and 
from mental anxiety and physical pain: she soon recovers her 
health and spirits, and is in general grateful for the relief, as much 
so, probably, as for any surgical operation whatever; but you 
cannot always do the operation. For example — some months ago, 
a lady came to me from New Jersey. She had been for some 
years laboring under a uterine disease, accompanied with violent 
and exhausting floodings. Upon arriving here, she was wholly 
unable to walk or to sit up in her chair. I discovered a hard 
polypus, whose apex was lying just within the os uteri, which was 
a circular opening as large as a half dollar. This os uteri was 
pretty low down in the pelvis ; it was very hard and completely 
undilatable. The fundus uteri was half way up to the umbilicus, 
and the uterus hard and solid, so as to allow me to trace its out- 
lines very clearly in my hypogastric palpation. I assure you, I 
have rarely met with a more extreme case of anaemia than in this 
person. This anaemia was evinced not only in the pallor of her 
surface and its flabbiness, and in her irregular breathing, the fre- 
quent palpitation of the heart, and the anaemical throb of her pulses, 
but in the state of all her innervations, which were most miserable 
indeed, except when lying profoundly still in a low recumbency. 

After a few days of refreshment from the journey, I attempted 
to do what I thought I should fail to do; namely, to get a ligature 
on the tumor. But I soon found how vain was such an attempt, 
for I never found the uterus a moment relaxed, nor to open beyond 
the size of a half dollar. My attempt caused an attack of hemor- 
rhage to come on that I was glad to suppress, by cold, by rest, 
and by opium. 
17 



258 polypus. 

I kept her here many months, in hopes of seeing the uterus 
enter into powerful contractions to throw off the morbid mass. I 
gave her large doses of ergot. I thought the ergotism that was 
produced, might expel the polypus, but I was disappointed, and 
subsequently had reason to believe the tumor had formed strong 
attachments to the inside of the uterine walls, so low down, that 
I could reach them with my finger, but could not break them up. 
During her residence here, I thought to see her bleed to death 
before my eyes ; her life was hardly saved by the tampon, so 
perverse was the hemorrhage. At length I sent her home, with 
directions as to her health, and a request to be informed if the tu- 
mor should descend into the vagina. It will never descend into 
the vagina, if the adhesions I supposed to exist are truly there. 

I have mentioned this case to you, in order to show you in 
the first place, that I could by no means cause that os uteri to 
dilate. ; neither by manipulations nor by force of the ergotic spasm ; 
and in the second place, and chiefly, in order that I might tell you 
what happened in the course of my treatment of it. It is this: 
she came here most deplorably ansemical. She continued here 
many months, during which time she always had some show, and 
suffered several severe floodings, one of which, as I have stated, 
was well nigh fatal. But except when reduced by copious flood- 
ings, she was raised, I was going to say, as by magic, into a 
state of ruddy health, by the daily use of Quenesville's metallic 
iron, in doses of two grains after each daily meal. 

I pray you do not accuse me of being credulous, and as argu- 
\3g a propter hoc, in a post hoc case. The phenomena were so 
striking and rapid, as to convince any one that they ought to be 
attributed to the power of that article over the blood membrane, 
the membrana vasorum communis. 

The greatest waste of her blood was followed by a rapid repro- 
duction of it, under the tonic power of the article. Do not say 
that it was her constitutional force that restored her; since, for 
years, she had been pale, palpitating, and exsanguious; whereas, 
under the use of the remedy, she rapidly regained all she had lost 
by the attacks. At all events, I pray you, when such a case shall 
present itself, and where you cannot get the offending tumor away, 
I pray you to test the power of microscopic particles of iron over 
the blood-making faculty, which, as I have so often repeated in 
your ears, I suppose to reside essentially in the endangium, a tis- 
sue which I deem to be as obedient to the therapeutical influences 



polypus. 259 

of iron, as the alimentary canal is to rhubarb or the uterus to 
secale cornutum. You see I speak very confidently on this topic. 
I confess, men suffer themselves to be readily deceived by what 
they deem experience. But, at least, I conceive that my expe- 
rience warrants me in this confident belief, a confidence which, 
while it is confirmed by my diurnal observations, is also enforced 
by the authority of such a writer as Raciborski, not to mention 
numerous authorities who give opinions, if not so approving as 
mine, yet at least such as to recommend the medicine to your 
careful study, as to its therapeutical powers. 

Upon reviewing this letter, I find that I have been less exact, 
and less full in my account of polypus than I intended to be. I 
shall not rewrite it, at least for the present; in fact, the question 
as to polypus, resolves itself principally into this, viz. : to disco- 
ver it, and to remove it by the ligature. That is to say, to re- 
move it when you can, not when you cannot ; but, you cannot, in 
cases where it is shut up within a contracted womb. Physic and 
drugs are useless in the view of counteracting or retarding the 
growth of such tumors. Physic cannot hurt the polypus ; but it 
can, and will hurt the patient. If, however, the patient bleeds 
too much, you must check or repress the flow. If the polypus is 
offensive, you must give such directions as may keep it free from 
that odious quality. If it gives pain, you must lessen the pain. 
I do not think you will get any advantage from caustics or cau- 
teries ; whenever such things are applicable, the ligature is appli- 
cable, and that will eradicate the evil. I beg you to receive this 
letter, imperfect as it is, with the assurances of that respectful 
regard, with which I am yours very faithfully. C. D. M. 



LETTER XX. 

Gentlemen : — In my last letter, which, as you may remember, 
I begged you to receive, notwithstanding I had prepared it with less 
care than I ought ; but which I concluded to send you notwith- 
standing my dissatisfaction with it, I did not say anything as to 



260 POLYPUS. 

those polypes that arise from the lip of the os uteri, from the 
canal of the cervix, or from the surface of the vaginai tself; nor, 
indeed, can I think it very much a matter of consequence to say 
anything of this sort of cases ; for as much as, the chirurgical na- 
ture and quality of these tumors being once established, nothing 
remains except to determine their existence; and then to apply 
the. proper remedy, to wit, the ligature. This task is compara- 
tively easy in these cases of polypus, because they are readily 
accessible, and may be subjected to strangulation upon their de- 
tection. 

Allow me, however, to put you upon your guard against a mis- 
take that you w r ould be liable to fall into in certain of these cases. 
I mean the instances in which the polypus is so small, that you 
can w T ith difficulty detect it by the touch ; and are even liable to 
mistake it when you do 'touch it, for a coagulum. 

I have seen one of these excrescences not so big as a grain of 
corn, and I lately removed one, not much larger than a grain of 
corn, for a patient who had suffered a constant wasting hemor- 
rhage from it for more than a year, to so great a degree, indeed, 
that she was rendered thoroughly anasmical by it, and suffered all 
the miserable effects of an ansemical innervation. 

I confess, I was surprised myself, upon discovering the polypus 
to be so very small; having expected to find one as large as a 
small pear at least. I was in doubt for a while, whether so great 
a waste could have depended on the effusion of blood from so 
small an excrescence ; but when I had taken it off, the waste 
immediately ceased, and the lady recovered her health and 
strength ; from which, I imagine, I have good reason to believe 
that the hemorrhage did, indeed, proceed from the polypus. 

I shall in a subsequent page inform you, that I cured a lady by 
means of the caustic acid nitrate of mercury, of a polypus spring- 
ing from the os tincse, and which w T as so small as not to be de- 
tected, save by inspection with the speculum ute^i. 

Pray, then, remember, that when you have perverse hemorrhages 
of the womb, not justly attributable to a menorrhagic cause, or to 
a large polypus, you may, perhaps, by careful exploration by the 
touch, or by the speculum uteri, make a good diagnostic so as to 
enable you to cure the patient, whom you could not cure should 
you happen to overlook the true organic cause of the trouble. 

I am afraid that I may in my letters, now and then, lead you into 



HASTY DIAGNOSIS. 261 

the error of jumping at a conclusion. You ought never to do that : 
you ought to arrive at all your conclusions in medicine, by a 
regular process of perception and of reasoning. Let me tell you 
a story about leaping at conclusions, which may serve better to 
put you on your guard, than ten pages of mere homily about pru- 
dence and cautiousness. 

A gentleman here, for whose medical judgment and chirurgical 
skill I have the very highest respect, called on me some time ago 
to request I would be present at the removal of a polypus uteri, 
for which he proposed to operate the next morning. He said, 
the polypus was already partially descended into the vagina; but 
the patient had been much annoyed by it, both as giving pain, 
and causing the loss of a good deal of blood. He had carefully 
made out the diagnostic of the case, and should be provided with 
a Gooch canula for adjusting the ligature. 

Upon reaching the rendezvous next day, I found a good many 
of the lady's friends assembled on account of the operation ; and 
of course no little anxiety was visible in their inquiring faces, for 
notwithstanding such an operation is a trifling matter in fact, the 
women will not so deem of it. 

My good friend informed me he had repeated his diagnosis, 
which was satisfactory; whereupon I was requested to examine 
the tumor, in order to found my own opinion. When we had re- 
tired to another apartment, I said, 

"Are you sure, my dear doctor, that your diagnosis is correct 
in the case?" 

" Oh, yes, certainly, I made it very carefully." 

"I am afraid you have made a mistake." 

"How?" 

"Why, I do not take it to be certainly a polypus." 

"What do you take it to be, then?" 

"I think it is a compressed ovum that she has been long cast- 
ing off, and that is now ready to come away from the canal of the 
cervix." 

"Oh no, sir, not at all; I assure you I have most carefully ex- 
amined it, and I am sure it is a polypus. Did not you observe its 
pear-shape, its smooth and polished surface, its resistance? It 
is clearly a polypus uteri." 

"Certainly, I do not like to differ from you in opinion on the 
case; I may be mistaken myself, but I shall be greatly obliged if 



262 HASTY DIAGNOSIS. 

you will do me the favor to repeat your examination, carefully 
noting the diagnostic differences of polypus, and the case I sup- 
posed. I am far from presuming on my own judgment, but I must 
doubt you will come to my way of thinking as to this matter." 

So he went to the patient's room, and soon came back, assuring 
me most confidently, that I had been mistaken, and that the case 
was a case of polypus uteri, pointing out to me all the infallible 
signs of that diagnostic. 

" Very well, doctor, it may be that I have made a strange mis- 
take, but you know that a man's perceptions are his percep- 
tions, and they are what he is to go by. I hope you will allow 
me, before the operation is performed, to correct myself by a new 
exploration." 

"Oh, certainly, I wish that you should do so, for I am quite 
sure you will find it as I have said." 

We went to the chamber; I passed the right index finger along 
the tumor into the canal of the cervix, which was considerably 
dilated by the ovum, and having carried it as high up as I could, 
I bent the last joint, indented the mass with the finger-nail so as 
to make it serve as a crotchet, and then exhorting the woman 
urgently, to bear down, — to strain, — hard, — harder, — the dead 
ovum slipped into my palm. 

I called for a basin of water, to put it in, and taking it to the 
window, I showed him the dead compressed ovum, of which the 
chorion and amnion were the irrefragable evidences. 

"What is it, doctor?" 

"It is an ovum." 

"I told you so." 

" Yes, but it is very strange ! Do you know that I have attended 
a thousand labors? How could I make such a mistake!" 

Now, do you, my friends, ask why I make all this detail of so 
simple an affair ? All medical practice is a simple affair ; it only 
requires, 1st, that you should be well informed as to the na- 
ture of your duties; and, 2d, that you should reflect upon 
those duties, in order to perceive what they be. The gentle- 
man in question is a man of talents, very superior to hundreds 
or thousands of our brethren. But you see what a mistake ! 
I make all this detail, in hopes of warning you not to frighten 
a whole household, by discovering that the mother of it has a 
polypus uteri, when she has no such thing. In fact, I make 



NASCENT POLYPUS. 263 

it to prevent you from jumping at a conclusion. How jump 
at a conclusion, say you ? Why ! certainly my friend did so ; and 
in this way. " The woman bleeds. She has a polypoid mass 
in the vagina, with certain uneasiness and pain; ergo, it is poly- 
pus, ergo, it must be extirpated. " He ought to have reasoned 
differently. He should have said, " The woman bleeds; she has 
bled not many days ; she has young children ; she is a breeding 
woman ; she has a polypoid mass in the cervix and vagina ; but 
a polypus requires a long time for its development; ergo, though 
polypoid, this mass is not polypous, it is an ovum, compressed, 
and which is grasped by the cervix ; I shall pick it away with 
my finger; and when it is done, I shall say, you are well, now, 
madam; the miscarriage is over, for I have the whole product 
of the pregnancy in my hand." 

I have no further remarks to make upon the subject of con- 
cluding too suddenly an opinion on such a case. If you will per- 
pend the circumstances I have just related, the facts, for they are 
facts, ought to serve to arouse your attention ; but, if you be 
really attentive to the business before you, how can you fail to 
make just and right conclusions ? 

Let me relate another case to you, which is that of a lady about 
six-and-twenty years of age, the mother of a child about two 
years old. 

Having for some time complained of pain apparently situated 
in the womb, and of vaginal discharge, and aching of the loins, 
and, indeed, of the pelvis generally, with increasing general de- 
bility, she was prevailed on to submit to an examination by the 
Touch. The os tincse was low down in the pelvis, and painfully 
sensitive ; but I could not discover any marks of swelling of the 
vaginal cervix, nor of engorgement of the whole uterus. 

By means of the speculum, I found that the os uteri as to the 
left half of its anterior lip was red, injected — the venules and 
arterioles being visibly enlarged. The color was that of the 
brightest and healthiest lip of a young person. The rest of the 
os tineas was of the natural pale whitish hue. 

I advised rest ; recumbency during part of the day, and all 
night; a regulated diet; and as for the local turgescence, I treated 
it with contacts of the nitrate of silver pencil. But I did not 
make any progress towards a cure. As soon as the effect of the 
caustic was done away, the redness was found to be more intense, 



264 NASCENT POLYPUS. 

and occupying a larger base. The substance of the inner aspect 
of the said lip, and as far up the canal of the cervix as I could 
trace it by sight, was red and swollen, and vascular. This vas- 
cularity augmented, and the mass became a small tumor, which 
began to hang outside of the os uteri, so that I could lift it, and 
move it about from side to side, and up and down, with the points 
of the speculum forceps; and, in short, it had converted itself by 
degrees into a cellulo- vascular polypus; very small, it is true, 
but a real polypus. I cut it down to the level of the surface 
from which it sprung, with acid nitrate of mercury ; but it sprung 
again, and again I cauterized it; and so for several repetitions, 
until at last the tendency of the part to develope a polypus was 
abolished, and now I consider the patient as cured. 

Have I not cured this patient of a nascent cellulo-vascular poly- 
pus of the os uteri ? I believe that I have, and the case is on that 
account rare, and worthy of your attention. The little tumor 
always carried with it an epithelial covering, which was so tender, 
that on some occasions it would give way and bleed, upon being 
touched very gently, with a plumasseau of lint. Perhaps some 
of you may think it was a mere vivace that I cured ; but I cannot 
but suppose that had I let it alone, it would soon have become a 
bleeding polypus, like the small one that I mentioned in a former 
part of this letter, and which caused so long and exhausting a 
hemorrhage from the lady. I am, &c. C. D. M. 



LETTER XXI. 

Gentlemen : — I showed you on several different occasions last 
winter, samples of uteri containing one or more hard nodular 
looking tumors, and also specimens, in which the entire mass of 
the womb had by disease, been converted into a tumor. You may 
remember that of the smaller tumors, some rose to a considerable 
height above the general level of the peritoneal surface ; some of 
them being mere knots, and others having the appearance of being 
attached by necks or peduncles to the superficies of the organ 



FIBROUS TUMORS. 265 

from whence, and through a faulty operation of the development 
force, they had sprung. 

You shall find cases in which a womb shall be covered with 
such botryoidal prominences. They are to be met with as large 
as a child's head, and of every intermediate size, down to 
that of a filbert or a pea. They are, doubtless, all of them poly- 
pes, and they differ from the other sort, of which we have been 
before speaking, only in this, that they grow in a direction to- 
wards the serous, instead of in a direction towards the mucous 
paries of the uterus. The same principle is employed in causing 
the growth of either sort. There are some of them that appear 
to have pressed themselves, or rather to have been pressed down 
into the substance of the uterine walls, and sit, as it were, like an 
acorn in its cup, but attached at the bottom of the cup by a root, 
neck, or peduncle. 

These tumors are not in themselves painful. They may give 
rise, however, to pain, by irritating the organ from which they 
grow, and yet they are not unfrequently met with in considerable 
numbers, in the uteri of patients who, having perished with other 
maladies, had never any suspicion of being affected in this way. 
In the long run they may be expected, however, to bring on dis- 
orders by disturbing the womb, which you know is eminently a 
disturbing organ, when it is itself disturbed. Upon attaining a 
certain size, they are likely also to introduce a bad state of health 
by their intrusion on the places of other organs and parts, whose 
circulation, absorption, nutrition, and innervation, they directly 
oppress and contravene by their mechanical displacement and 
pressure. 

People talk of taking medicines for such tumors, and they even 
take homoeopathic pellets in decillionths of grains! Leaving out 
of question the unspeakable nonsense of the homoeopathic dosings, 
I see not on what ground they should take even real physic for 
such complaints, since drugs cannot, and were never designed 
to heal such tumors and make them return under obedience to 
the natural development laws of the organ, and restore its outline 
and contexture to a normal form and dimensions. 

Don't you see that these are really chirurgical maladies, — that 
is to say, they would be subjects for chirurgical manipulation and 
operation, provided they could become accessible to the lingers, or 



266 FIBROUS TUMORS. 

bistoury, or ligature, &c? True, Mr. Lisfranc has proposed to 
enucleate them, and possibly, when one of them happens to spring 
from the vaginal cervix, it might be turned out with the handle 
of a scalpel, or dug out with the finger nails, ff you like such 
surgery, it may be well, but I confess I am not of that class of 
people. As to doing anything with those that grow outwards to- 
wards the peritoneum, I look upon it as hopeless. I detest all 
abdominal surgery, save that which is clearly warranted by the 
otherwise imminent death of the patient. I say imminent death, 
not inevitable death, for death is ordained for us all. 

It does not, however, follow, that because you have come to the 
conclusion, that nothing can be done in the way of curing a 
fibrous tumor of the womb looking towards its serous surface, 
you are to do nothing for the patient herself. 

Much may be done in a way of wise counsel and prudent pre- 
scription as to her conservation ; as to putting off the evil day ; 
as to obviating and combating all the provocatives to an unneces- 
sary increase of the malady; and as to counteracting the effects 
of pressure and intrusion, the natural accompaniments of the tu- 
mor. She maybe confined, by your orders, to the house, the sofa, 
or the bed, whenever the disturbance arises to a height rendering 
such intervention of yours desirable. If obstruction of the pelvis 
attend the complaint, the enema, the aperient, the strong pur- 
gative, are at hand, under your direction. Her diet and clothing 
may be regulated wisely and usefully. If inflammation and pain 
be threatened, or actually make the attack, you will save the 
perilous organs by your venesection, your leechings, cuppings, 
counter-irritants, stupes, and cataplasms; by your tartar of anti- 
mony and potash, your calomel, and your opium. So that when 
you cannot cure the fibrous tumor, you see I do not advise you 
to turn your back on the patient, leaving her to an inevitable 
fate, rendered tenfold intolerable by unwise treatment, or by no 
manner of treatment. For I deem those who are doomed to an 
inevitable and not distant death from incurable disease, to have no 
less need of the physician than those who are certainly curable ; 
and I think no higher exercise of the medical functions can ever 
be found than in those euthanasial benefactions that can smooth 
the way of the dying, and through composure, and comfortable 
counsels, and charitableness, and "sweet oblivious antidotes," 



SERRES J VIEWS. 267 

divest of some portion of their terror and pain, the last fast fleeting 
hours of men. 

I am, my dear friends, in no little danger of making a ram- 
bling sort of letter of this, as well as the last one ; for I find myself 
disposed very strongly to come back again in this one to the con- 
templation of principles that I find I have partially discussed in 
the former. I hope, however, that as I am writing letters, and 
not a regular book, you will pardon me if I depart from the regu- 
lar epopoeia form of book-making, and preserve in this series of 
communications the liberty and latitude which would be unbe- 
coming in a regular gradus operis. In fact, I am very desirous 
to lay before you a translation of part of Article XVII. of M. 
Serres' Anatomie Trans cendante, which is at page 130 of that 
admirable work; and I do this, because I feel very sure that no 
one is likely to republish the work in this country, and that you 
will probably not have an opportunity to seethe passages in ques- 
tion, unless I give them to you here. You will judge whether 
the citation be german or not, to the matter in hand, to wit, the 
abnormal developments to which the womb is liable. 

Mr. S. says, " The structure, as well as the form of organs, is 
subject to various metamorphoses. An organ passes through va- 
rious phases or gradations, before it reaches the condition in 
which it is destined to remain throughout the rest of its exist- 
ence. An aberration of its form produces monstrosity ; an aber- 
ration of its structure produces disease. Both these aberrations 
are subject to certain rules, and very nearly to the same rules. 

"In order to conceive just ideas of an aberration of form, we 
must follow the successive evolutions of such form from the mo- 
ment of its first manifestation, up to the period of its complete 
development. 

" To conceive of aberrations of structure, we must adopt the 
same plan. But, inasmuch as a case of monstrosity is nothing 
more than the retrocession of an organ towards another and more 
simple condition of such organ, or its arrest at one of its embryo- 
nal and primitive conditions ; in the same sense, an organic dis- 
ease is often nothing else than a return of an organic tissue 
towards a textural condition, which it naturally possessed at some 
one period of its embryonal life. 

" Diseases consisting in retrocession of tissues, correspond to 
cases of monstrosity by default; and monstrosities from excess 



268 

approach, in their nature, those morbid conditions in which there 
is a new organic production. Now, as a monstrosity by excess is 
but the repetition of an already acquired organization, so, produc- 
tive maladies can never give rise to any other than already exist- 
ing tissues. They reproduce tissues, as monstrosity reproduces 
organs; and these tissues as well as these organs almost always 
have their analogues in the normal and regular organization. 

"Thus, the reproduction consists in a cellular tissue — in a 
membrane, the basis of which is cellular tela, or albumen ; or it 
is a cellular part, becoming a fibrous part; and the latter passing 
into the osseous, or cartilaginous state ; or, the product consists 
in natural cartilages, in which ossific matter is deposited; in 
strange muscular fibres that exhibit themselves ; in organs of secre- 
tion that are formed, either in the state of cysts or of crypts, whose 
analogues already exist in the economy ; or there are blood-ves- 
sels rising up spontaneously in newly-formed tissues, and, in fine, 
the nervous system itself may come to add itself to these acci- 
dental products. 

" Notwithstanding they are formed in the midst of disease, 
these productions are subject to certain laws. The first law is this ; 
and it confirms one of the laws both of physics and chemistry, 
viz., that as a slow action is necessary for the operation of a regu- 
lar crystallization, so a slow action is indispensable for the ac- 
complishment of these formations. A rapid action would pro- 
duce either the destruction of the organs, or a hemorrhage, or 
collections of sanguine, or serous matters, or even purulent depo- 
sits, in which no organic movement is discernible. 

" The second law is a consequence of the former; and it is that 
the growth of these products is effected by means of juxtaposition. 
The membranous layers superimpose themselves, one above the 
other where the membrane is plane ; if, on the other hand, it is 
bent or curved, so as to form a cyst, the addition is made upon 
the interior, in a concentric manner. The exterior in this man- 
ner becomes the internal membrane of the cyst, which is nothing 
more than the membrane rolled up. This difference in form, 
slight as it is, produces a very great difference in the result ; for, 
whereas the membrane can acquire nothing beyond an individual 
existence, limited, at most, to the mere production of the sangui- 
ferous apparatus, the cyst frequently becomes a real organ, the 
interior of which deposits fluids of various nature and consistence. 



269 

It may even constitute a being, self- existing, and become a first 
degree of animality. The third law relates to histogeny, pro- 
perly so called. 

"It was, no doubt, an error of the ancient anatomists to perse- 
vere as they did, in the search after an elementary tissue or fibre, 
the origin of all other tissues or fibres. Yet, underneath this idea 
lay concealed the profound and true notion that tissues apparently 
very different have, in fact, the very same origin ; and consist but 
of the same element subjected by the powers of nature to diverse 
modifications. 

"Thus, the cellular element, when disposed in areolae, or in 
fibres, constitutes the system to which it gives name : in bundles, 
it is the fibrous system ; rolled up so as to form a closed sac, it be- 
comes the serous system, &c. These various systems are nothing 
but natural and normal transformations of one common element. 
But, if it be in nature to undergo these transformations, we may 
perceive how a cellular part in man may, like the posterior cervical 
ligament, become fibrous in certain animals; how a ligamentous 
part such as the stylo-hyoid ligament, maybe transformed into an 
osseous chain ; how cellular parts may become serous membrane, 
while the serous membranes of the last order may become re- 
placed by cellular tissue, &c. 

" We may also conceive that diseases, by modifying this 
common element, as nature modifies it in a normal state, shall 
cause cellular to become fibrous, cartilaginous, osseous, and 
serous parts, &c. All these modifications of a common element, 
may be converted one into another, while still circumscribed 
within their proper limits. The same will be the case as to the 
nervous and muscular elements, each of them forming systems 
analogous to themselves, although differing among themselves. 
In fine, the vascular, or sanguiferous element, intervenes in all 
these diverse systems, as a condition of all, in a somewhat ad- 
vanced formation. 

" These analogous systems transform themselves each into the 
other, without, nevertheless, overleaping their respective limits. 
The cellular, will never, under any circumstances, clothe itself 
with those characters that are proper to the nervous or the mus- 
cular element, nor will the nervous or the muscular elements ever 
exhibit the evident conditions of the cellular. However varied 



270 SERRES' VIEWS. 

may be such accidental products, you will ever find them cir- 
cumscribed by their true special nature. 

" The very contrary of these statements is to be found in most 
of the treatises on pathological anatomy, wherein you are told that 
all the tissues, commencing as cellular, may again take upon 
themselves this transformation. In those treatises you find ac- 
counts of cellular, fibrous, cartilaginous, and even osseous trans- 
formations of the nervous system and of the muscular system. 
The fact is true; its explanation is not true: the nervous system 
is never, in any phasis of its development, cellular. According 
to our views, therefore, it cannot, under any circumstances, 
manifest the transformations that are peculiar to the cellular ele- 
ment. But, incontestably, these metamorphoses are observed 
in it: then, it must be because the cellular element intervenes. 
How should it intervene? Always by accident. A solution of 
continuity suddenly separates portions of the nervous matter of 
the encephalon or spinal cord and nerves, a cicatrix repairs the 
injury. Such cicatrix, at first cellular, may become mucous, 
provided it fills with pus; it may become fibrous, cartilaginous, 
and even osseous ; I have met with, and reported cases of each 
sort. But we see that in these cases, which I have analyzed 
with the greatest care, the nervous element remains entirely a 
stranger to these transformations. It is the cellular tissue, which, 
supervening pathologically in the nerve-matter, becomes the basis 
and the seat of these metamorphoses. Here, as everywhere 
else, it undergoes the evolutions peculiar to it, and to itself only. 

" The practical consequences of these principles are so easily 
deducible, that, for the present, I shall refrain from deducing them. 
I will, however, remark that these new formed tissues never do 
attain the full degree of development, of the normal tissues to 
which they approximate. Thus, the osseous transformation may 
produce laminse, or granules, but never anything comparable to 
a bone. The cellular transformation of cicatrices is very far re- 
moved from the natural disposition of that tissue; a serous cyst 
can never produce a pericardium or a pleura ; nor, will the acci- 
dental mucous membranes ever rise to the height of that rich 
organization which we observe, for example, in the intestinal 
mucous membrane. Disease produces an abortion of tissue, just 
as monstrosity produces an abortion of organs." 

There, gentlemen, I know not what you will say, or what you 



FIBROUS TUMORS. 271 

-will think of such a long extract in this letter, but I know what 
you ought to think, and that is, that you ought to think yourselves 
much obliged to me, for giving you an opportunity to read the 
above beautiful and philosophic exposition. I advise you, before 
you go any farther, to turn back and read M. Serres' remarks over 
again. It will do you good to read them again, and it will do your 
patient good, for they are replete with the wholesomest doctrine 
constantly applicable to clinical ministrations, and perhaps, indis- 
pensable to a correct understanding of the diseased morphology 
of the uterus, which is the special subject of this letter. I did not 
intend to make so copious an excerpt from any body, but I could 
not resist the temptation to present this one from that admirable 
philosopher. And I am sure there is not an ingenuous and intel- 
ligent young man among you who will not concur with me in 
thanking M. Serres for even this much of his profoundest thoughts. 

Having now laid before you M. Serres' observations as above, 
let us proceed with the more direct object of this letter. 

What was the real nature of that immense and very firm mass of 
polypus that I mentioned in the beginning of this communication? 
I said it was fibrous, and I suppose that that fibrous matter, though 
not truly a mass of uterine matter, must have nevertheless been 
deposited under a development or accretion law, identical with that 
which originally developed the fibrous matter of the womb itself, 
though modified in its operation by disease in this instance. 
Uterine polypus may be cellular or cellulo-vascular. In such 
cases, the vascular and cellular elements become the subjects of 
diseased deposit; in the former, the muscular or fibrous portions 
are chiefly the subjects of it. 

But you saw specimens last winter, in which the entire mass 
of the womb became altered, having grown to a vast size, and 
retaining in its augmentation very few of the characteristic features 
of its normal fabric. It, in fact, is become under such circum- 
stances, a heterologue organ, or rather, is converted into a tumor. 

Those cases wherein the whole womb is converted into a tumor, 
are very different from the mere hypertrophic modifications of its 
volume and weight, and the tumor is different in different samples, 
according as one or as another of its normal elements has been 
the chief subject of the morphological transformation, and the de- 
parture maybe greater or less in different specimens, some retain- 
ing, and others losing every trace of the original character. 



272 FIBROUS TUMORS. 

In regard to all the possible forms into which the material ele- 
ments of the womb may become converted under the wild hetero- 
logy operation of its development force, where it has abandoned 
its generical law, it seems to me nearly bootless to inquire. 

Some of the writers on these strange appearances have endea- 
vored to classify them and reduce their arrangement to a scien- 
tific scale. For my part, it seems to me enough to know that the 
elements may, each of them, undergo changes by a morbid act of 
deposit, and I am not, therefore, surprised to find a hygroma, a 
hsematoma, a lipoma, a cancer, &c, formed upon the basis of 
the uterine textures. If the morbid development deposits-in the 
uterus a mass of cartilaginous structure, there is no reason for 
surprise when that cartilage passes into bone, since it is one of the 
functions of cartilage to do so. All such cartilage deposits are 
effected through the agency of cells, and Thomas Schwann has 
shown, in his "Comparison of the Development of Animals and 
Plants" that in each of those kingdoms, the cell life force is the 
agent of nature in the work of evolving her living forms. 

You will readily admit, that this cell force moves in a true 
generic line partly in virtue of an original nature or bias with 
which it is endowed, and partly in virtue of certain chemical at- 
tractions that concur with it; for example, the cells of the chorda 
dorsalis of a tadpole, are probably very different in their original 
life endowment from the cells of the pollen tube of a cactus or a 
lily; yet even if you presume them to be not different in the 
essential nature of their nucleated nucleoles, they are very differ- 
ent as to the circumstances in which they are placed ; for the 
chorda dorsalis cells could not possibly be developed in such a 
cytoblastem as that which is provided for the pollen cells in the 
stigma or style of a vegetable, and vice versa, for the pollen cells 
could find no proper elements in the albuminous fluid of the spinal 
marrow. 

Now, as to the morbid tumors of which we have been speaking, 
the cell — the mother-cell — finds a new cytoblastema in a morbid 
deposit, and it appropriates it to form a tissue, a morbid one, but 
still a tissue, which is heterologue, and to such a degree, that it 
will be difficult in many samples to ascertain which is the devi- 
ated element in the case. 

If you examine the cells of a malignant tumor, you shall often 
find no appreciable difference between their appearance and those 



FIBROUS TUMORS. 273 

of the healthiest young growing part, as for example, the cells of the 
chorda dorsalis, those of cartilage in very early embryos, or those 
discovered by compressing the pollen grains of a flower, or the 
plumule of a bean. 

The caudate cells of some of the cancerous tumors, the acicular 
crystals, the granules and laminae of earthy phosphates and car- 
bonates that we find in these masses, ought not to excite our 
surprise, though they may well overwhelm us with grief, if like 
the good Sir Thomas Browne, whom I have already quoted, we be 
not only grieved, but thoroughly ashamed, that there is in the 
w r orld, not only the greatest of evils, death, but that other great 
evil of diseases incurable. 

I do not imagine, my young friends, you will make any very 
great progress in real knowledge, by burdening your memories 
with all the varieties of nomenclatural distinctions, that are in the 
books concerning tumors of the womb. 

Dr. Hooper's costly and beautiful volume, " The Morbid Anato- 
my of the Uterus and its Appendages," is one of the clearest of 
them, but I think you will find in it too elaborate a systemization 
of these vagaries of the development forces, an attempt to classify 
what need not, and indeed cannot be classified, videlicet the freaks 
of nature, acting without generic law, or end, or aim. It is far 
better to study M. Serres' beautiful doctrine, that I have quoted 
for you from his Anatomie Transcendante, in which is explained 
the true philosophy of such extraordinary operations. 

You shall probably meet, in the course of your long experience, 
with cases where the womb, that w T eighs in its natural state only 
two ounces, has become as large as a man's head, and weighs 
many pounds. The texture here is not uterine texture ; it is a 
mixture of fibrous and cellular material, with greatly diminished 
proportions of vessel, nerve and absorbent. It seems to me that 
the process of production for this abnormal uterine matter is one 
that has no natural term ; it is limited only by the life of the pa- 
tient, and there is no power to recall it. It is, therefore, useless 
to give drugs with that view. It is true, I have met with several 
examples of enlarged and heterologue uteri, that have ceased 
to grow, and I can well imagine that now and then in the pro- 
cess of extension, there will be attained a final term of the deve- 
lopment force. That is to say, the uterine and spermatic arte- 
18 



274 FIBROUS TUMORS. 

ries that serve under the registry of the accompanying nerves, 
may convey material sufficient to carry out the morbid formation 
to a certain extent, but cannot transcend that certain extent, 
because the calibre of the vessels will not admit of a sufficient 
quantity of blood to pass to effect any further accretions, or haply 
the accompanying nerves will lose, by their extension, their indi- 
cating or controlling vital power over the morbid organic acts of 
accretion. 

Such an effect as I have just spoken of, would doubtless follow 
the tying of both the uterine arteries ; or, perhaps even of one of 
them ; and in any case where a uterus should be known to be 
about to convert itself into a solid tumor, it seems to me not an 
impracticable surgery to secure the uterine arteries, with a view 
to suppress the further development. 

Suppose, in any such case, Robt. Lee's ganglions of the cervix 
uteri could be carried off by a dextrous operation, would not the 
further development of the tumor certainly be arrested ? 

I repeat that I have seen some cases of morbid augmentation 
of the womb carried to such an extent as nearly to fill the whole 
of the excavation of the pelvis ; so much so, indeed, as greatly 
to impede the functions of defecation and urination, and wherein 
the patients, after years of great suffering, have recovered their 
activity and good health. 

In such samples there has been, however, a loss of appetite, or 
a regulation of the diet amounting almost to the diete absolue: 
and there is reason to suppose that the cessation of development 
has arisen from the extreme reduction of the development force, 
partly by feeble health, and partly from the diminution of the 
sources of supply under a rigorous diet. 

I saw a cancerous mamma, as hard as cartilage, ulcerated, and 
firmly adherent, that was totally removed by absorption, in a long 
paraplegia. 

Many of these great tumors of the whole womb are accompa- 
nied with dreadful hemorrhages. After death, you find a uterine 
cavity longer than natural, but not much more spacious. The 
walls of the cavity, however, are many inches in thickness. 

I attended, for a long time, a lady with a vast tumor of the 
whole uterus. She had enormous uterine hemorrhages. The 
uterus weighed many pounds; its cavity was not much larger 
than the normal size ; in the right ovary, which was as large as 



FIBROUS TUMORS. 275 

the fist, was found a quantity of human hair. Probably, the fatal 
development of the womb was provoked by the irremissible irri- 
tation communicated by the ovary to the uterus. 

In case the womb begins to develope itself as a uterine tumor, 
it will in the stages be sure to sink low down in the excavation of 
the pelvis; and as it developes its magnitude more and more, it 
more and more interferes with the parts upon which it presses. 
If you touch such a mass, you scarcely shall fail to find it firmly 
packed, or jammed in the pelvis, putting you in mind of those 
cases of immobility of the womb that I spoke of in my XVth 
Letter. If you let the uterus go on increasing in size and 
weight while inhabiting the excavation, you^will be sure to have 
much trouble from complaints of urinary and intestinal tenesmus, 
that must inevitably accompany such pressure and intrusion. 
Reflect for a moment on the facts, and you will perceive that 
though apparently immovable, the mass is not really so; and that 
it is only apparently so from the condensation of the tissue of the 
vagina, and from its weight. If you could get the tumor well 
raised upwards, so as to carry the mass of it above the superior 
strait, you would do the woman a great service, by relieving her 
of all the painful and annoying accidence of the malady. But, 
when you try, with your hand to raise it, it will not go! Don't 
be disheartened ; make it go. How? Place a globe-pessary in 
the vagina, a small one ; one of an inch and a half, or an inch 
and three-quarters ; leave it in situ for a week, more or less; then 
adjust one of two inches, and next one of two and a quarter 
inches. In this way you may very confidently expect to raise 
the tumor out of its narrow bony chamber in the excavation, 
which is too small for its accommodation, and get it up into the 
free and large space of the abdomen, where its pressure is scarcely 
inconvenient. But, think, gentlemen, if you take away by this 
means, a constant and irritating tenesmus, you turn aside in that 
very act, a strong and perpetual provocation of the sanguine and 
nervous systems to excessive activity, and thus diminish the tend- 
ency to rapid growth of the tumor. Nay, might it not be that the 
growth should find itself completely arrested in this way? I am 
convinced that the abolition of a constant and vexatious tenes- 
mus would be far more efficacious in diminishing the tendency to 
morbid nutrition and development of the womb, than half a dozen 
leechings, cuppings, or blisterings, to which you would resort as 



276 FIBROUS TUMORS, 

your chief therapeutical armamentaria medico-therapeutica. But 
in this, I speak not as one theorising only ; I speak from what I 
regard as well-observed clinical experience of my own. 

One is greatly tempted, under such circumstances, to pre- 
scribe; and, if we must prescribe, let us allow the woman to test 
the power of the deobstruents, as they are called. Such is the 
iodine. 

I have no clear rationale to offer you as to the therapeutic action 
of iodine. Its probable efficacy, as combined in the spongia usta, 
in the cure of bronchocele, led it into a great vogue as a means 
of promoting the actions of the absorbent system; and there can 
be no reasonable doubt as to the disappearance of swellings of 
glands after its exhibition ; of the disappearance of various cuta- 
neous eruptions ; and also of certain engorgements of organs. But, 
whether tumors are obedient to its power, is a question not yet 
settled ; for a tumor is a new material, and not simply an old one 
modified as to size, sensibility, and. resistance. Nevertheless, you 
would probably give the patient iodine. Let her take it for along 
time. Let her take it in combination with some of the diet 
drinks; as Zittmann's decoct., or decoction of the woods; or 
simple infusion of sarsaparilla ; or, what is the least inconvenient 
of all, the compound syrup of sarsaparilla. Let her have five 
drops of LugoPs solution of iodine, with half a fluidounce of syrup 
of sarsaparilla, twice or thrice a day. One good effect of such a 
drug may be counted upon ; and that is an improvement in the 
state of the skin, which becomes warmer, more humid, and better 
colored under its use, and if so, then the internal determination is 
in so far lessened, which is a great point gained. 

The use of the bath at 96° or 98° of Fahrenheit, will conduce 
favorably to the same end. If repeated too frequently, it will be 
found exhausting. I advise you to order the bath about three 
times a w r eek, and that the patient go from the bath to bed at 
night. 

Seeing that the w T omb is subject to a monthly hemorrhage, in 
consequence of the periodical ovi-posit by the ovary, and that this 
mensual hemorrhage absolutely depends on a periodical hemor- 
rhagic engorgement and nisus of the internal reproductive organs, 
it is a clear duty to regulate the patient so as to cause the monthly 
periods to pass by with the least possible injury to the womb. 

If the woman whose womb is about converting itself into a 



FIBROUS TUMORS. 277 

tumor should be careless of her menstrua ; if she allow them to 
be checked or prevented, and the vessels and the nerves of the 
organ to remain too long, or loo considerably under the influence 
of the mensual .nisus, the tumor will be surely aggravated by 
that protracted or too violent sanguine and nervous determina- 
tion. Let her, therefore, be advised to stay at home ; to keep her 
feet from cold pavements, or grass, or earth ; to maintain a solu- 
ble state of bowels; to diminish her rations; to be calm, and 
gentle in all her movements, and in all the affections of the mind 
during the existence of the mensual crisis. 

It will be advisable also to abstract her constitution from the 
too considerable irritation communicated by the tumor, acting 
upon and vexing that constitution day by day, and nightly, for 
w T eeks and for months. Small doses of opium in the form of 
Dover's powder at night, alternating them from time to time, 
with enemata of black drop, or laudanum, will be the most pow- 
erful means within your control for such ends. But, as you will 
have a long case before you, you should be careful to avoid op- 
pressing the nervous system by a profligate use of such narcotic 
remedies. The nervous system is more apt to be debauched than 
saved by the intemperate use of such drugs. Let your doses, 
therefore, be the smallest possible ones consistent with the pro- 
duction of a moderate therapeutical result. 

I cannot close this letter, without again saying to you that 
women, in whom the whole mass of the womb becomes converted 
or metamorphosed, are very liable to uterine hemorrhages. The 
change in the constitution of the uterus, does not of necessity 
implicate the healthful vitelliferous and germiparous operations 
of the ovaries ; but the ovaries, and not the womb, contain the 
cause of the menstrua. Hence, the menstrual action goes on in 
some of the specimens with very great regularity. It is to be 
noted, however, that the new condition of the uterus itself, com- 
monly renders it hemorrhagic, and the same causes and influ- 
ences, therefore, which produce the healthful mensual elimination 
in the healthy uterus, operate to cause an excessive discharge of 
the menses, in some of these altered uteri. As to two females, in 
each of whom the womb was as large as a man's head, the waste 
was very great. 

To combat such wasting discharges, you have at your com- 
mand the usual resources of local cold, of recumbent rest, of 



278 FIBROUS TUMORS. CANCER. 

opium, of saccharum saturni, of alum, of krameria, kino, &c. 
&c. But, I have seen all these fail, and yet the hemorrhage 
held in check, by doses of a decoction of dewberry root, and 
black currant root, taken in half-teacupfuls at a time, and re- 
peated pro re natd. I mention it here, as an article worthy of 
your attention, especially in the examples of hemorrhages in 
which you find yourselves baffled. The ultima ratio, the tampon, 
will, of course, ever supply your wants in the instances wherein 
it may be indicated. 

Lastly, never despair; never give up the patient; never pro- 
nounce the case hopeless, even when it is to all appearance hope- 
less. Not that I advise you to deceive the sick, or their friends, 
which is cruel and useless ; but you should remember, that men 
and women and children, have recovered from even apparent 
death. In these cases of enlarged womb, you have the hope 
that the growth will cease, and you have the example that they 
sometimes diminish again. It is time enough to pronounce that 
there is no more hope, when the life has left the body. I have 
seen the life resumed, even when I had regarded the signs of 
death as complete. 

I wish, my friends, I had more comfortable prospects to hold 
out for you than those which, as to tumors of the womb, are con- 
tained in this letter. Medicine is always making progress, how- 
ever, and let it be your duty so to study, to observe, and to reflect 
upon these mighty disorders, as to enable you in the next half 
century, to leave more consolatory counsels to your pupils, than 
I can to mine. C. D. M. 



LETTER XXII. 

Gentlemen : — There is a frightful malady to which women, 
the subjects of these letters, are very much exposed; I mean car- 
cinoma, or malignant degeneration of the womb. 

I have little to say on this subject, and, I might add, there is 
little to be done for those who are attacked with it ; I mean little 



CANCER OF THE WOMB. 279 

to be done under prospects of curing the persons so attacked, or 
restoring their health. 

It is enough to make a physician's heart sink within him to 
make the diagnostic of cancer uteri, for such a diagnostic is ipso 
facto a prognostic of death ; and when the physician has made it, 
and is brought to the point of giving true expression to his opi- 
nion, he might be supposed to be as painfully situated as an Eng- 
lish judge, when he puts on the black cap before the final an- 
nouncement of the judgment unto death. 

It is probable that the double functions of the uterus, as a men- 
struating and a child-bearing organ, render it more liable to the 
attack of this atrocious malady, and that its structure, also, which 
in the healthful state is solid, hard, and elastic, without excessive 
abundance of circulation or nerves, exposes it more constantly to 
the causes of carcinomatous change. 

What is that condition, that carcinomatous condition which re- 
sults in ulceration or open carcinoma of the womb ? and how is it 
originally established and set up in the texture of the cervix ? Do 
you say it is cell-life begun and carried on there ab initio ? How 
is the cell-life begun? — what gives origin to it? — when does the 
cell development begin ? — is cancer always an inoculation, and 
whence the inoculation ? — can the healthy actions of the womb 
deposit mother cells in a healthy texture, and furnish them with 
the indispensable cytoblastem, without which they would die ? 
These are questions more easy to propound than to answer, be- 
cause physicians, very rarely enjoying opportunities of inquiring 
into the rise and progress of these disorders, do not begin to ob- 
serve them until they have reached a stage of development so 
advanced as to leave little ground to expect any advantage from 
treatment, beyond the mere benefits arising from cleanliness, and 
some suppression, perhaps, of the progress as well as of the pain 
and irritation. Such cases cannot be studied ab initio. A mere 
schirrus of the cervix does not give pain, and the woman herself 
will not ask our aid or our opinion on a case of whose existence 
she is not aware. I say, then, we cannot study these carcinomas 
ab initio. They can be reasoned of, however. 

I have never been able to bring myself to a consent that these 
diseases are the results of anything but inflammation. I have 
always regarded the transformed materials of a carcinomatous 
cervix, as the transformations of deposit brought about by inrlam- 



280 CANCER OF THE WOMB. 

matory action. And, if you will keep in view the remarks of M. 
Serres as to the gentle and slow progress of those actions that re- 
sult in morphological changes, you will not find it difficult to 
agree with me that a carcinoma is an inflammatory result; for the 
slowness of the process, of which M. Serres speaks, is an attri- 
bute of those chronical inflammatory movements which produce, 
not hemorrhage, not secretions, not pus, not sphacelus, but new 
textures. But a carcinoma is a new and a changed texture. It 
is an imperfect texture. It is a texture whose combination of 
vessels, absorbents, and nerves is a perishing and unpermanent 
one ; one that, from the very nature of the proportions of these in- 
struments and agents of life, cannot exist long in one tenor of life, 
but must change and decay from the very fault of their crasis or 
composition. In a healthy cervix, the accretion and waste are 
duly balanced, because the absorbent and the nerve are there to 
regulate them ; but when, in consequence of a slow, a chronic 
inflammation of the cervix, the interstitial textures become filled 
with laminae, or fibres, or bands, or granules of coagulating lymph, 
or fibrine of the blood, it is manifest that the vessels are to be 
collapsed or compressed and closed by these deposits outside of 
them, as is clearly shown by Pujol, in his admirable doctrine of 
inflammation; and that the absorbents are sealed or compressed so 
effectually, and the nerves so absolutely destroyed, that the quasi 
organization of the carcinomatous cervix has come to its end, its 
term, and no longer, in truth, exists as to the sum of the particles 
of the cervix; and then commences a process of absorptions, and 
sloughings, and suppurations, and hemorrhages, and macerations, 
and sanious putrid excretions, which proceed until the constitu- 
tion of the victim being entirely exhausted or overthrown, she 
sinks into the grave, her only and her last best refuge. 

In the progress of this half erosion or maceration, and half 
phagedenic ulceration of the parts, the mother cell makes its be- 
ginning; and once begun, the parts once inoculated with this 
new and wild, unconstrained, uncontrolled form of life, the de- 
struction goes on with rapidity ; nothing stays, nothing arrests it, 
and the sole resource of our art consists in the exhibition of opium 
in some one of its forms, for the subduction of the distress. 

The principal matter, however, is to make a correct diagnosis. 
There is danger of an incorrect one in this, that if you come to 
the clear conviction that the case is one of veritable carcinoma or 



CANCER OF THE WOMB. 281 

cancer, you will be paralyzed by that conviction; and, like every- 
body else, will settle down in the conclusion that nothing is to be 
done beyond the administration of those palliatives, which, though 
they cannot cure, yet can console and comfort the patient. 

I have certainly met, in the course of thirty years, with several 
cases of diseased uterus, which I had the greatest reason to sup- 
pose cancerous, but which yielded to persevering treatment, and 
ended in the perfect recovery of health. 

Far be from me the intention to proclaim that I have been more 
fortunate than my brethren, and that I have cured cancer of the 
womb. My desire is to say that I was mistaken in my diagnosis, 
and that I treated a curable and not an incurable malady. I am 
of the opinion that everybody holds on the subject of this terrible 
evil, viz., that it is one of the opprobria medicorum, and that it 
cannot be cured. No, not even by the excision of the part 
affected. I speak of the true cancer. 

Dr. Muller, in his work on the Nature and Structural Characteris- 
tics of Cancer, &c, combats the opinion of Wenzel, that scirrhus 
and carcinoma are mere inflammatory induration, followed by 
ulcerative action. Yet, notwithstanding my ready assent to the 
doctrine of cells, as the agents of vital development, I confess 
myself to be quite in favor of the doctrine of Wenzel, and of 
those who, while they deny not the destructive activity of the de- 
veloping cells, which are so readily detected in various forms of 
ulcerated carcinoma, and of fungoid disorders, yet regard the 
antecedents of cancer as caused by inflammation. Perhaps you, 
my friends, may be in favor of Prof. Muller's views, and I ac- 
knowledge his arguments are very powerful, and that his citations 
of examples and varieties in the forms of cancerous degenerations, 
add to the force of his reasoning. But I cannot bring myself to 
believe that cancer ever commences anywhere, asapunctumsaliens 
of disease. There is always an antecedent state of alteration of 
tissue ; a state which lays the foundation for the wild evolution 
and increase of cells, out of and beyond the control of the accre- 
tion and waste laws of the part or organ. 

When a part has once become changed by a certain form of indu- 
ration, the control of the generic nerves is abolished in it ; and a 
cell deposited within it, or inoculated from without it, might live 
and multiply upon its morbid cytoblastema, so as to result at last 
in the strangest modifications of the texture ; becoming carcinoma 



282 CANCER OF THE WOMB. 

reticulare, alveolare, fasciculatum, melanodes, or medullare. 
These several forms of degeneration depend on the loss or re- 
tention of more or less of the nerve-power of the part, by which 
one or another of the constituent elements of a fabric may be held 
in check, or allowed to run into riot and ruin, under the action of 
the disease. 

But it is not my purpose, and I confess I have not sufficient 
information upon these points, to enter into a useful discussion of 
the microscopic characteristics of the various forms of cancer. 
There seems little profit in such discussions, beyond that which 
enures to the enrichment of our possessions in biology. They 
will probably have but little influence in a utilitarian sense, since 
they add not to the power of the therapeutist, nor to the success 
of the surgeon. I cheerfully refer you, therefore, to Prof. Muller's 
beautiful work, hoping, however, that you will always endeavor 
to exercise an independent judgment on all matters of science; 
not without that due respect to the superior knowledge and oppor- 
tunities of such men as John Muller, whose great learning and 
noble devotion to the enlargement of the boundaries of medical 
science, have earned for him so distinguished a name. I shall 
refer you to Colombat for a fuller description of the phenomena of 
scirrhus and cancer of the womb ; merely saying here that, when 
the os tincae becomes covered with hard lumps, that feel like shot 
lodged under the epithelium, that give sharp pain when pressed 
with the finger; that deform the os uteri, by causing it to swell 
unequably; by unnatural discharges; you will have a right to 
suspect scirrhus. If it have gone so far as to bleed for a touch, 
and to give rise to sanious discharge, with a peculiar odor, not 
very different from that of carious ulcer, it is ulcerated cancer, 
and the patient will die. 

You will find that many of the European surgeons have treated 
cancer of the cervix, by cutting off the diseased part, and that 
they assert the patients to have been sometimes cured by the ope- 
ration. I think the remark made to me by an eminent Philadel- 
phia surgeon some time since, is worthy of being repeated. " If 
the cervix was cut off," said he, " and the woman recovered, it 
affords the most incontestable proof that the operation was unne- 
cessary." It is probable that the course of your future expe- 
rience, in recovering certain forms of enlargement, induration, 
and ulceration of the cervix uteri, will bring you, in the end, 



CANCER OF THE WOMB. 283 

to a similar conclusion. In fact, there have been so many cases 
of excision of the cervix, within thirty years past, with so little 
happy result, that the operation is understood to be nearly aban- 
doned by the German and the French surgeons. T. S. Lee says, 
" I have seen but one case of this kind, (excision of the cervix :) 
the neck of the womb was entirely removed, leaving an open 
cavity in the womb. After the operation, the patient remained 
in the hospital some long time, until the ulcer caused by the ope- 
ration had entirely healed; but, after her dismissal, she shortly 
had a return of the deep-seated pain in the pelvis, the dragging 
at the groins, inability to walk far, and many of the same symp- 
toms of which she complained before the operation. M. Lisfranc 
states that the success of this operation is very great in his hands ; 
but he can hardly be relied on. It is an operation not much prac- 
tised by our own surgeons, on account of the liability of the dis- 
ease to return. Caustic is our only resource when the granula- 
tions become too luxuriant ; but I have never seen it do much 
permanent good. Opiates are constantly necessary to allay the 
deep-seated and other pain which disturb the rest and break up 
the constitution. Conium and hyoscyamus are the best; they 
affect the head less, but frequently are not sufficiently powerful ; 
then opium, in some form, must be had recourse to. The bowels 
are to be kept gently open: but, diarrhoea is to be avoided." 

What more? I am out of heart, and ashamed to name cancer 
of the womb ; and yet, what is the miserable victim to do without 
the aid of the physician ? You must aid her. You must wash 
away the foul and putrid collections that actually sometimes gush 
from the diseased surfaces. 

If you treat such cases, you may add greatly to the comfort of 
the woman by the upward douche. You can suspend a glissoir 
and conduct into it a pailful of water, at such temperature as you 
please to indicate ; the lower end of the glissoir, if provided with 
a gum-elastic tube, may be carefully introduced into the parts 
while the patient reclines in a bath-tub, or sits on a bench over a 
wash-tub, so that the douche may be directed to the affected parts 
with the effect of lessening the accidental epiphenomenal inflam- 
mation, and carrying away all the detestable odour of the sanies. 
Or the patient may go daily into a sitz-bath, and cleanse herself 
of the odious exhalations of her malady. What a comfort for a 
woman! 



284 CANCER OF THE WOMB. 

Dr. Lee says that caustic is the only recourse. Take a small 
phial containing acid nitrate of mercury, a camel-hair brush with 
a long handle, a speculum of ivory and a speculum forceps, a 
small sponge, some honey of roses containing wine of opium or 
black drop, or extract of conium, or extract of hyoscyamus. 

Let the patient lie across the bed, her head, not the shoulders, 
on one single pillow; her hips at the very edge; her feet on the 
upper bars of the backs of two chairs ; her knees widely separated, 
covered with a sheet. 

Introduce the cylindrical or conical speculum, not too far, wrap 
the edge of the sheet all round the tube, so as completely to con- 
ceal the person, leaving only the projecting portion of the tube 
to be seen. Press the speculum down slowly and gently until 
you disclose the diseased part. You will be sure almost to find 
some of it upon the vaginal walls. DonH burst them, nor hurt them 
by jamming your tube into them. When they come into sight, 
take your bit of round, soft sponge filled with Castile soap, dip it 
in tepid water, thrust it into the mouth of the speculum, and then 
holding it in the forceps, carry it to the bottom of the speculum 
and wash the ulcer clean. A soft sponge, well filled with fine 
Castile soap, is as soft as the mucous membranes themselves, and 
may be freely but gently turned round and round over the granu- 
lations and shreds, without inducing hemorrhage or the least pain. 
On the contrary, the patient is greatly comforted and consoled 
by the process, both physically and morally, for her pain is 
diminished and she feels herself to be less an object of aversion 
and disgust when the frightful foetor of her cancer is even tempo- 
rarily taken away. 

Having cleansed the surfaces and dried them with soft dossils 
of charpie or linen cambric, if the indication calls for it, dip the 
camel-hair pencil in the acid nitrate, and carefully conducting it 
to the granulating surfaces, touch them with the solution ; where- 
upon they immediately assume a gray or ash color ; and the se- 
cretions are, for the while, suspended by the coagulation and 
cauterization of the orifices and surfaces of exhalation. When 
you have made the contact of the caustic, carry your sponge, 
filled with warm or tepid soapsuds, to the bottom of the speculum, 
in order to neutralize any excess of the acid that might flow ofF 
upon surfaces you do not wish to act upon ; and then having dried 
the sore again, dip a. small bundle of charpie or soft linen cambric 



CANCER OF THE WOMB. 285 

in the mixture of honey of roses, attaching a strong thread to the 
bundle; place it in contact with the ulcers and keep it there with 
your forceps, until, by gently withdrawing the speculum, you 
observe that the collapse of the vaginal walls will hold it in situ. 
The patient may withdraw the pledget or plumasseau in the 
course of four, six, or ten hours, according to the heat of the apart- 
ment and the heat of her body. The thread serves to draw it 
away. 

Dr. Lee tells you to use conium or hyoscyamus as your ano- 
dyne ; but he also says they are not very reliable resources, and 
that you must come to the opiates at last. In the matter of opiates 
you should reflect that in addition to the debauching influences of 
opium on the nervous constitution, and on all the secretory acts, 
there is a directly pernicious impression on the primae viae. But 
you should save the digestive power as far as you can. Use the 
laudanum, therefore, as enema, and use it wisely. Teach the 
poor creature not to waste so great a blessing as that which God, 
in the midst of his chastisements, has vouchsafed to her. If she 
uses her anodyne too much, like a spendthrift, its power will soon 
be gone. 

Let her, then, in the beginning, learn to quell not to crush the 
pain, for it will rise again. She should be provided with a 
proper syringe, one that will hold two fluidounces, and no more; 
and the fistula plumbea should be of a good size and sufficient 
length. Let her add to two tablespoonfuls of clear starch, twenty- 
five to forty-five drops of laudanum, or eighteen to thirty drops of 
black drop, or two to four teaspoonfuls of solution of morphia, to 
make the injection into the rectum — an injection that may be 
repeated once or twice, or thrice in twenty-four hours. She 
should be clearly informed that the progress of her malady will 
surely require larger doses, and the larger the doses the worse 
the influence upon the digestive and nervous pow r er. Teach her, 
then, not to be profuse in the expenditure of that treasure of com- 
fort which she possesses. 

Where you have under your care cases that are attended with 
wasting discharges of blood or sanies, from cancerous tumors of 
the cervix proper, that sometimes are tuberous in form and of a 
large size, Ipresume you will as readily counteract the bursting 
tendency of the tumor, or its tendency rapidly to pullulate like the 
granulations in what is commonly called proud-flesh, by using the 



286 CANCER OF THE WOMB. 

acid nitrate. You may, perhaps, prefer the caustic potash. But 
the most efficacious and sudden of these powers, is that you pos- 
sess in the actual cautery. The greatest objection to it in this 
country is the terror and the talk it would excite. But it does 
not give pain nor cause sensation, and the death of the points 
touched by the hot iron is so complete and so deep, that it is more 
efficacious than any potential cautery, and leaves a better base 
after the fall of the slough. 

It is very easily applied through an ivory or horn speculum. 
You ought not to employ a silver, or metallic speculum for this 
operation, because, in using the actual cautery, you must have 
the iron intensely hot; if it be merely cherry-red, it will adhere 
to the surfaces that you touch with it, and you will tear them in 
removing it. Your bouton should be white-hot ; when, indeed, 
it burns before the actual contact, and does not adhere to, but 
rather repels the surfaces. Now, if you pass a white-hot cautery 
down the whole length of the metallic tube, you will heat the 
tube, and burn the whole vagina, whereas, if you pass it down 
an ivory or horn cylinder, which is a non-conductor, you will 
give her no pain at all. 

Many of you, living in remote country places, will? perhaps, not 
find it convenient to procure the beautifully turned ivory specu- 
lum; but there is everywhere to be got a cow's-horn. Cut one to 
the length of six inches; drill or reame out the interior to the dia- 
meter of one and three-quarter inches at top, by one and a half 
inches at the lower end ; shave it thin and polish it, and you will 
have as good a speculum as if Charriere himself had made it. You 
would do well to have several, of different sizes, for in some of 
the carcinomata of the uterus and vagina, you will want a very 
small cylinder, inasmuch as a full sized one would give pain and 
even endanger the laceration of the vagina. 

M. Jobert de Lamballe, one of the surgeons of St. Louis, at 
Paris, is very famous in Europe, for the common use he makes of 
the actual cautery, in the treatment of diseases of the os tincae. It 
is, in fact, for him a great specialty. M. Jobert, in a publication, 
has supposed the cervix to be nearly destitute of nervous sensi- 
bility. He treats a great variety of disorders of the cervix, by 
this means, and asserts that many of his patients are completely 
cured by it. 

I have seen him apply the cautery to many women who came 



CANCER OF THE WOMB. 287 

in succession, to place themselves on the bed arranged in his 
lecture room. The iron was always brought to him by an aid, as 
soon as the speculum was properly adjusted. The hiss of the 
burn was distinctly audible, but the women were never sensible 
of the contact, as I was assured, both by carefully observing their 
expression of countenance, and by their own avowal ; for they 
assured me they felt nothing, though, in the course of a little time 
afterwards, there was heat and pain, which soon passed away. 
M. Jobert himself is very confident in the vast benefit of this pro- 
cess ; but the English on the opposite side of the channel, detest 
his process, and condemn it. There is>,no objection, however, 
to your making use of it, for the suppression of otherwise irre- 
pressible fungoid growths, or perverse hemorrhagic discharges. 

So much I have said as to cancer. I sincerely wish it were in 
my power to say more ; but I can find no encouragement in my 
own melancholy experience, nor in the writings of Recamier nor 
Lisfranc, or Duges and Boivin. 

But, for the cases that simulate it; that present hardened and 
patulous os uteri, with granulations that bleed for a touch, and 
that sit on a hard and swollen base ; if the patient be not already 
reduced in strength and flesh, bleed her from the arm, purge her 
every alternate day, with compound powder of jalap and cream 
of tartar, until she has taken four, six, or eight doses. Touch the 
granulations with the nitrate pencil ; keep the woman in bed ; 
direct the frequent use of the bidet; let her have a tepid-bath 
three or four times a week ; give her a diet, in which she shall 
have some meat every alternate day at dinner, and only then. 
Dissolve a grain of corros. chloride of mercury in a pint of com- 
pound syrup of sarsaparilla, and direct a tablespoonfu] for a dose, 
twice a day, to commence after the close of the course of purga- 
tives. An anodyne enema at night will not only procure sleep, 
but procure that sort of hebetude as to constitutional impression, 
that is highly conservative under these circumstances. 

Such a diet as I have advised above, I have for many years 
been in the habit of recommending in long cases, and I have pre- 
ferred it to a continued abstinence from animal food, because the 
digestion is less apt to give way under it, than in a diet of lavage 
or mere vegetable matters, and moreover, the patient submits with 
greater cheerfulness to a restriction that is not absolute. In such 
a course of diet, the patient in thirty days will have taken only 



288 PHYSOMETRA. 

vegetable matters on fifteen of those days, or thirty days in sixty, 
which, for many cases, will be found a sufficient degree of absti- 
nence. 

Certainly, I have cured some very unpromising forms of dis- 
eased os and cervix uteri, by such a course. And now I shall 
desist from further remarks on this painful subject, referring you 
to the publications already mentioned, where you may find greater 
details, but little more encouragement; and I am very truly, &c. 

C. D. M. 



LETTER XXIII. 

Gentlemen :— If you will look into the books, or listen to the 
relations of your patients, you will, perhaps, be led to believe that 
the womb is occasionally to be found distended with air, which, 
after having caused it to expand, until it attains the size of a 
womb six months gone with child, more or less, suddenly escapes ; 
whereupon the signs of the woman's pregnancy disappear to the 
great astonishment of the hopeful patient, as was the case in the 
celebrated instance of Mrs. Commodore Trunnion, of whose baby 
the author said, " tenues in auras evadit." These ventose 
pregnancies are nonsense, and no thoroughly-bred and close 
thinking physician ought to be for a moment misled by such a 
story. It is against physiology; it is against pathology, and it 
flies in the face of common sense, to talk of collections of wind 
distending a material like the womb, a material which creaks 
under the edge of the bistoury, and expanding it like a normal 
ovum, whose gentle slowness of growth is the sole reason for the 
deployment of the gravid uterus. 

Air is too subtle to remain quietly locked up in a bottle 
that has no cork in it; and you all know very well, there is no 
womb into whose cavity you could not thrust a large quill, or 
male catheter; how, then, is air to remain in the womb, and blow 
it up like a Freshman's football, not only against the resistance 
of the womb itself, but against all the succussions of the abdo- 



PHYSOMETRA. 289 

minal muscles and diaphragm, and the resistance of the skin of 
the trunk of the body to boot! It is an idle conceit. 

What! is there no such thing, then, as physometra and tympa- 
nites uteri ; or a discharge of wind from the womb ? Has it never 
been heard? Yes, I have heard it many times, both in child-bed 
women, and in others. Yet I repeat, that inflation and distention 
of the womb w T ith gas, the ventose pregnancy, the pet vaginal 
are not diseases, but pure accidents. Madame Boivin and Duges, 
at page 134, say, " We have never known the existence of an 
aeriform body in the uterus, except in obstetric cases, as in reten- 
tion of the membranes, or of portions of the dead foetus, or of 
putrid coagula, causing gaseous exhalations, found in the uterus 
after death, or escaping per vaginam during life." 

Let me explain this matter to you, fori cannot patiently endure 
to think that a pupil of mine, be he settled in Maine or Wiscon- 
sin, at the Sault St. Marie, or Monterey, should admit to a patient 
that the womb can become filled and distended with gas, as a 
result of diseased secretion, for such secretion is impossible, and 
to admit it ridiculous. 

I have often been present at the discharge of large quantities 
of gas from the genitalia. A woman shall be seized with her 
last labor-pain, and bearing down with great violence, thrust not 
the child only, but the placenta also forth upon the bed; and, in 
bearing down with the violent force of the labor-tenesmus, she 
pushes the very womb itself to the bottom of the pelvis, shorten- 
ing the vagina in so doing, wrinkling and crushing it dow T n to the 
os magnum. As soon as the tenesmus is over, the resiliency or 
elasticity of the tissues recovering its power, the womb rises 
again to a certain height within the excavation of the pelvis ; but, 
as it is a cul-de-sac that rises, it is natural for air to follow it, and 
the vagina, and the womb itself, may thus contain air that has 
been drawn up within them, upon the same principle as that 
which makes it follow the movement of a piston in a cylinder. 
Then comes a new pain — an after-pain ; or else I apply my hand 
to the hypogastrium to make sure of a good contraction of the 
womb. If I compress the womb with my hand, and particularly 
if I push it downwards in the pelvis, I am very apt to cause a 
quantity of air to rush out at the ostium vaginae, with consider- 
able noise. This I have heard a great many times. So, in making 
19 



290 PHYSOMETRA. 

the examination per vaginam, when the uterus is very low down, 
or when in making use of the speculum I push the os tincse far 
away from the os magnum, air enters the passage, and follows the 
retreating womb. If it be left there, and the woman is seized with 
a fit of coughing, or if she moves quickly, or changes her posi- 
tion, the air is pressed out with the sound of the pet-vaginal. And 
there is no other way to account for it, that is reasonable. So, also, 
a woman has a heavy womb, with a large loose vagina ; she lies 
on the couch or bed ; and the uterus retreats, as La Motte says, 
drawing air after it; but she rises, or coughs, or turns, and 
the air is expelled. These occurrences give you no colorable 
ground to suppose that she secretes air from her genital mucous 
membrane; did you ever hear of air being secreted by the blad- 
der of urine? Never. Air is not secreted. The bubbles of it 
that you see upon the skin, are not bubbles of secreted air; they 
arise from the vaporization, or from the transformation of fluid 
products on the skin. 

A fish even does not secrete the air of his swimming bladder. 
He comes to the surface for it. 

If a woman sends for you, with a distended abdomen, with 
suppression of her catamenia and other signs of pregnancy, and 
complaining also of the pet-vaginal, I pray you be not so thought- 
less as to tell her that her womb is distended with air, for it is not. 

Auscult the patient, and percuss the abdomen, and explore it 
by means of palpation, and if she be not pregnant, you may say 
she has a tympany, or ascites, &c; but do not say she has a 
flatulent womb. I would as lief hear you had told her she has a 
flatulent right ventricle of the heart or ventricle of the brain. 

If, as Madame Boivin says, there be a putrid placenta corrupt- 
ing and rotting within a lately delivered womb, or lying in the 
vagina like a huge putrescent tampon, you would not be surprised, 
upon taking it away, to find it followed by a gush of foul air, 
which, it is said, has even been found to be inflammable. In ex- 
tracting the putrid placenta, I have not only had to submit to the 
horrible offence of this putrid blast from the womb, but I have 
found the decaying mass of the after-birth crepitating under my 
hand like a putrid piece of emphysematous lung. 

But in these cases the passage has been closed by the decay- 
ing mass ; and you might suppose that a very firm clot or a quan- 
tity of chorion and amnion left in the womb after labor, could so 



PHYSOMETRA. 291 

shut up and close the orifice as to detain within the globe the 
putrid or other gases formed or extricated within. 

It might even happen that an ulceration of the canal of the cer- 
vix with luxuriant granulations, should shut up the mouth of the 
womb ; and that some of the fluids detained above the obturation 
might extricate gases : but that they could expand the uterus so 
as to make it large as the womb at five months, is what I cannot 
conceive of, and if I should, like Frank, meet with such a case, I 
would not believe it. I would rather believe I had made a mis- 
take in my diagnostic. 

A woman might well have an escape of air from the os uteri, 
who had had a utero-rectal fistula, a thing quite possible after ad- 
hesion of the utero-rectal peritoneal cul-de-sac. 

Well, then, as I do not believe in a physometra as a disease, 
but only as an obstetric accident, I have nothing more to say 
about it, except that when your patient complains of it to you, 
and is disquieted and alarmed about it, I hope you will make her 
understand that she is not the subject of any sickness, but only of 
an accident. 

Although I have nothing more to say about physometra, I have 
something to observe about those supposed pregnancies that consist 
merely of wind — wind in the bowels. 

Certain nervous women, of child-bearing age, and certain wo- 
men about the change of life, are liable to suppose themselves 
pregnant because the abdomen is enlarged and the catameniahave 
not returned. 

A young lady of my acquaintance was married, and went to 
another city to reside with her husband ; there she became preg- 
nant, as she supposed, and when about seven months gone, came 
to see her family. Her physician, w T ho had seen her in her new 
residence, had pronounced her pregnant, and all the charming 
prospects and tender sentimentalities connected with these new 
scenes for the newly married, w T ere hers. 

Soon after her arrival here, I was hastily called on account of 
a threatened premature labor, as she had a considerable show. 
Upon reaching the apartment, the scene of much anxiety, and 
after making inquiries as to the stage of the gestation, the amount 
of the hemorrhage, &c, I placed my hand upon the abdomen 
to discover whether the womb was condensed, and found the 
belly so uniformly distended up to the scrobicle, and so soft and so 



292 PHYSOMETRA TYMPANITIS. 

free from any hard uterine outline or delimitation, that I pushed 
the bunch of my fingers gently down to the plane of the superior 
strait, and could almost carry them to the promontorium without 
encountering any obstruction from womb or child. Next I ob- 
tained permission to examine by the Touch, and discovered the 
uterus to be non-gravid. What did I do next ? — or what do you 
think I ought to have done? My patient was already sufficiently 
agitated and nervous with all these palpations and explorations. 
If I had* at once communicated to her the result of my researches, 
I should have had a scene. I reassured her — I told her there was 
no danger ; and then, in another apartment, I communicated to 
her mother the disappointing intelligence, warning her to break it 
gently to the young lady, which was judiciously effected. 

My patient, after having some treatment adapted to the morbid 
innervations of her alimentary canal, recovered, and returned to 
her home. The symptoms, after a few months, returned, and at 
six or seven months of the gestation, the medical man, who de- 
clared on this occasion that she was not pregnant, resolved to 
bring her doubts to a final term ; whereupon he gave her a strong 
dose of physic, which brought away a young dead foetus. ' The 
same patient crossed the Atlantic, and became pregnant in Eu- 
rope. Her medical men permitted her to embark for the United 
States at an advanced period of gestation, and she reached her 
native place in safety. When she came here I discovered it to 
be another attack of tympany. After this, her health being better, 
she again conceived, and had an abortion of about two months' 
gestation. 

Now these were not examples of physometra, but of tympanitis. 

A lady twenty miles from town was pregnant — her physician 
agreed that she was; — her monthly nurse was engaged here, and 
near the term was conveyed to the country residence to be in 
readiness for the accouchement. The accouchement came not: 
the nurse remained six weeks in waiting. The physician at length 
wrote me a letter giving an account of the case, and sent the lady 
to town. I percussed the abdomen with flatulent resonance on 
the whole superficies of the belly, which was a uniform tympa- 
nitic tumour, and not a uterine tumour. "You are not pregnant," 
said I; " you are resonant upon the whole abdomen, down to the 
very hypogastrium, and there is no click of the foetal heart. The 
motions you have felt and the distention you have suffered were 



PHYSOMETRA TYMPANITIS. 293 

motions of borborygmi and the inflation by gases in the intestines. 
Take these doses of physic : buy a yard of fine flannel ; tear it into 
strips, four inches wide, to make a swathing bandage; wrap the 
long bandage round the abdomen, round and round, as tight as you 
can bear it without inconvenience, and reapply it daily. Com- 
press the bowels and they will not yield to the lateral distending 
pressure of the gases developed within their tubes: your abdomen 
will become as small as ever." And so it was. She took her 
physic ; she wore her bandage ; she recovered her digestive health, 
and her physometra or wind pregnancy disappeared. She after- 
wards became really pregnant, and I delivered her here. 

I had a lady about 48 years of age under my care. She was 
anxious to have a child: had been long married, but there was 
no blessing. At length I was apprised of the approaching good 
fortune. I percussed the abdomen, and I detected the denying 
resonance everywhere. I ausculted in vain : there was no click 
of the heart, and I announced my diagnostic. My flannel roller 
on the abdomen, some aperients and tonics cured the physometra. 
How many cases of this gestatio-ventosus have I seen! I have 
assuredly never, no, not in a single instance, announced or ad- 
mitted a pregnancy in such circumstances ; nor will I ever do so ; 
because I will never say to any woman, "you are pregnant," 
until I know it. 

The faults in these cases of chronic tympany — I mean those 
samples of it that are unattended with any severe or violent and 
dangerous local disorders, such as ulcers of the bowels, &c, are 
readily curable with a roller of flannel, about four inches wide 
and three or four yards long, which should be turned round and 
round the belly, covering the half of the last turn with the suc- 
ceeding one, and securing them all neatly with strong pins or a 
needle and thread. 

Nobody could have chronically inflated bowels but from debility 
or insensibility of the circular muscles of the alimentary tube. 
Now, that debility or want of action may arise from a faulty in- 
nervation, begotten in general debility, sedentariness, certain 
affections of the mind, and in many examples, symptomaticallv or 
sympathetically by the reproductive disorders: — a woman, for 
example, ought to menstruate regularly; she stops menstruating — 
nobody can tell why — she has not very visibly lost her embon- 
point, nor has she taken cold, or met with any moral or constitu- 



294 PHYSOMETRA TYMPANITIS. 

tional shock, and yet she does not see ; who can tell whether she 
produces germs or not? It is very possible that her ovi-posit goes 
on as regularly and perfectly as ever it did, but that the consenta- 
neous irritation and excitement, instead of being propagated to the 
womb, is propagated by the various plexus-connections to the 
splanchnic system of the belly, and betrays itself in these false 
or wind pregnancies. I do not know that it is so, but if any one 
should suddenly die, or be killed while so affected, and a recent 
cicatricula ovi-positionis should be detected in the ovary, I would 
hold it a strong evidence of the above rationale, and of course I 
would say that the tympanitis had been an hysterical manifest- 
ation. 

Tympanitis is often a hysterical manifestation ; for a woman in 
an attack of hysteria generally has copious eructations at the close 
of the fit. 

I was called into a jail, in the State of Georgia, thirty-two or 
thirty-three years ago, to see a young girl who was seized there 
with an alarming attack of hysterical convulsions. I well remember 
to have been sitting by her bed-side as her convulsions went off, 
and seeing her abdomen rise and rise and rise, to such a vast size 
of distention, and that visibly, as to its progress, that not I only, 
but all the persons about her, feared the belly would burst like a 
shell. I have never seen such an example since. It required but 
a few minutes for the abdomen of the girl to become as large as 
that of a woman at term. 

Now, pray take notice that these distentions could never take 
place, but as being permitted to occur, by the yielding of the circu- 
lar peristaltic muscles : wherever these peristaltic muscles do their 
physiological duty, they do it by compressing the contents of the 
bowels, whether solid, fluid, or gaseous, while those contents are 
compelled to move along the intestinal tractus, in the direction of 
or in a line with the peristaltic motion. If you discover, therefore, 
that your patient has lost this power of compressing the intestinal 
contents, you will reason about it, and you will say, "I can re-ex- 
cite this lost power. How? By giving the patient a purgative 
or an aperient, or eccoprotic dose, for that is the meaning and in- 
tent of such a dose. I shall give some rhubarb, senna, or pur- 
gative drug, and I will cause all this gas to be expelled." 

It is very well for you to reason in this way, but you will be 
disappointed upon the trial, for your purgative will purge the pa- 



TYMPANITIS. 295 

tient, and the bowel will discharge all its stercoraceous contents, 
and much liquid and mucous matter, but the gas will stay in, and 
the belly be as big after, as before the operation. You cannot 
get along, however, without your purgative, or aperients; and 
when you choose them, pray take my advice, and use one of Dr. 
Brown's formulas. I have used it for many years, and if it was 
not unprofessional to do so, I would imitate the epigraph I have 
seen in many old ladies' family recipe-books, and write over it 
prohatum est. 

Dr. Brown was a famous physician who lived at Port To- 
bacco, in Maryland, many years ago. He was one of three bro- 
thers, all of whom obtained considerable eminence in medicine, 
in their own districts and States. He was the Dr. Brown who 
was called in consultation with Dr. Dick and Dr. Craik, at the 
last illness of Gen. Washington. My master, Dr. Thomas Han- 
son Marshall Fendal, of Georgia, was his pupil, and he told me, 
thirty-eight years ago, that this was one of Brown's formulas. 
Dr. F. used it in almost all severe cases of tympanitic disorder, 
and I have used it ever since, and ever shall. 

Take one ounce of manna; 

One drachm of anise seed ; 
Eight ounces of boiling water. 
Mix them, and let the mixture rest for half an hour, then strain 
the liquor. 

To the strained liquor add three drachms or four drachms of 
carbonate of magnesia, so as to make a perfect mixture. 

A wineglassful may be given for the dose, to be repeated every 
two hours, or three hours, until it operates. This is Dr. Brown's 
carminative cathartic, and if a man may venture to speak on 
an experience of thirty-eight years, I am willing to say that I 
have all that time found it the most dependible carminative phvsic 
that I know of; and I heartily recommend Dr. Brown's formula 
to you. 

I do not pretend to know why it is the most efficacious dose in 
tympanitis ; nobody knows why one medicine acts thus, and 
another so; it is enough to know that ipecac, makes you vomit, 
and that jalap purges you. The why, is a metaphysical, if not a 
psychological proponendum. 

If, in the treatment of these wind pregnancies, or tympanies, 



296 TYMPANITIS. HYDROMETRA. 

you can get the bowels once to discharge the flatus which seems to 
stay, in some instances, for weeks and months, in one even tenor 
of tension, you will gain an important point. If you can do it, 
then pray tighten the flannel roller, and keep all the advantage 
you have gained by aiding the weakened intestinal muscles to 
compress the intestinal contents. Keep up the activity of the 
muscles of the bowels, by means of an aloetic, such as Lady 
Webster's pill, or by draughts of infusion of rhubarb, quickened 
with some compound tinct. of rhubarb or senna. 

Let her drink brandy and water with her dinner, and a hot 
glass of punch at bed-time ; have a good index expurgatorius of 
eatables, in which you should carefully set down sour-krout, pork, 
veal, duck, goose, beans, beets, corn, and id genus omne of the 
wind-begetting vegetables, that are fitter for the dura messorum 
ilia, than for the tender intestinal constitution of hysterical ladies. 

Some of the doctors will tell you, for they still do insist on it 
with me, that these wind-swellings, these tympanites are produced 
by collections of gas secreted in the peritoneal sac. 

I should be astonished at any one of you, could I hear him say 
he had a case of tympanitis of the pericardium, arising from secre- 
tion of gas by that serous sac. I should be equally astonished 
to hear any one of you attribute an ordinary tympany of the belly 
to such a cause. The air in tympany is always in the bowel; 
never outside of it. Farewell. C. D. M. 



LETTER XXIV. 

Gentlemen: — The womb is sometimes distended with water, 
which, after having enlarged it to a certain size, suddenly gushes 
forth, leaving the organ to return to its non-gravid size. This 
state is called hydrometra, or dropsy of the womb. 

Now, as to hydrometra, I do not believe in it. It is indifferent 
to me who has seen it, or who has heard of it. I repeat, I do not 
believe in such a malady, and therefore I had serious intentions 
of passing over it in silence. The womb is a cul-de-sac, which 



HYDROMETRA HYDATIDS. 297 

can hold no water, except when the mouth of the cul-de-sac is 
turned upwards, in which I admit it would be possible for it to 
hold a little water; but, when the mouth of the cul-de-sac is 
turned downwards, the water would run out of it, as surely as it 
would fall out of a teacup or tumbler, that you should turn upside 
down. 

Still, they say the womb fills with water, and becomes as large 
as the gravid womb at seven months. There is no doubt of it ; 
I have seen it; but that does not make a dropsy of the womb; it 
is only a case of a womb expanded by a body growing or en- 
larging within its cavity. 

It is said an acephalocyst, or rather a half million of acephalo- 
cysts, might develop themselves in the womb. These acephalo- 
cysts, or bladder- worms, fill with water by some process of absorp- 
tion, or endosmosis, and as they expand, the womb which does 
not know it is not pregnant, yields to the delusion, and gives way 
to the internal pressure, just as it does under the pressure of a 
growing healthy ovum. The acephalocysts fill more and more, 
until at last, the womb will no longer tolerate the incumbrance, 
and beginning to contract, soon expels the intruding masses by a 
regular process of labor-pains. 

When the mass is expelled, it is found sometimes to be in quan- 
tity sufficient to fill a wash-hand basin, and you call it a mass of 
hydatids. These hydatids look like bunches of grapes ; like the 
finest Malaga grapes, and are of various sizes, from an inch in 
diameter, to that of a small pin-head. Each one is attached to a 
mass of partially organized matter, consisting mainly in laminar 
cellular tela, with blood-vessels creeping among the grapes. 

I have seen them come off with very great hemorrhage, even 
to fainting. 

I said they are called acephalocysts. I ask you whether that is 
likely; and whether each one of the grapes of a bunch of hyda- 
tids, is to be esteemed an independent ens? 

I have never heard of hydatids in the virgin, nor do I believe that 
a virgin could have an hydatid or anything like it developed 
in her womb. I have met with them only in married women. 
I do not regard them as hydatids, or acephalocysts ; but I think 
they are morbid products of conception. 

A woman shall conceive healthfully, and carry on the gestation 
for a few weeks, when the embryo dying, she ought to throw oiV 



298 HYDROMETRA HYDATIDS. 

the ovum by an act of abortion; but she does not do so. The 
ovum having formed its mesenteric attachment, keeps up a sort 
of life within its textures, and the floating extremities of the villi 
of the chorion imbibe, by means of the endosmosis, the transpa- 
rent fluid which you see in the bunches of hydatids. They are 
not animals, they are dilated and hypertrophied villi of the cho- 
rion. A bunch of hydatids is a dropsical placenta, and a drop- 
sical placenta is the dropsy of the womb, or hydrometra, of which 
you have heard. To have a true dropsy of the womb, you must 
imagine the os uteri hermetically sealed, and the cavity of the 
organ filled, and distended w T ith serum. That would be a dropsy. 

It is said that a single acephalocyst, or living hydatid animal, has 
filled the womb to a great size, and suddenly bursting, has dis- 
charged its whole fluid contents, at a gush. I have never seen such 
a case, but I have seen many times a pool of water on the flow, 
from rupture of the ovum, where I know the ovum was not rup- 
tured. Such pools of water were hysterical discharges of urine. 
And, as I cannot conceive of a c}^sticercus, or acephalocyst, large 
as a child's head, I prefer to suppose that the doctor and the patient 
have both been deceived, than that so improbable a magnitude 
should ever be attained by an animalculus. 

In true pregnancy, the womb is occupied by the ovum, whose 
growth causes the womb to grow pari passu. The ovum in preg- 
nancy, consists of the embryo or foetus, the cord, the placenta, 
the amnion, and the chorion. The ovum is a living, independent, 
self-supported creature. It may well be likened to an acephalo- 
cyst, and yet its head might be stated to be the placenta, which 
attaches itself to the uterine walls, and sucks or draws from 
thence the materials for the development of itself, and its depend- 
encies. Its dependencies I say; and by that word, I mean to 
imply the child, and all its parts. The child may be regarded 
as one of the complex organs of the acephalocyst, which perishes 
at the end of a prescribed term, leaving the organ it has deve- 
loped, a complete and self-existent creature, as it had itself been 
before it. This is the only true single acephalocyst that I can 
conceive of, as filling and distending the womb to a great size. 
And this acephalocyst may become morbid, that is to say, it may 
become enormously overgrown, so as to distend the womb beyond 
measure, and greatly interfere with the woman's health, by the 
distention and intrusion. The w T omb itself may be injured, or 



HYDROMETRA. 299 

weakened, by the extension; and the constitution may suffer 
from pressure of an overcharged womb on the vessels and 
nerves, and other organs in the belly. 

A womb, in this sense, might be said to be dropsical ; but, 
rather, it would be truer to say the ovum is become dropsical. 

In general, there is no remedy for this dropsical state of the 
womb, of which I now speak. Not that you could not readily 
bring it to an end; for nothing could be easier than to do so, by 
pushing a catheter through the os uteri, and through the chorion 
and amnion, to let off the water. The escape of the water 
would end the dropsy, but I hope you will not think of resorting 
to such a treatment for any degree of inconvenience that might 
arise from the over-distention, short of one involving the woman 
manifestly in danger. You have no right to bring on anybody's 
labor, but upon the strongest and most clearly understood motives 
of necessity, and of indispensable necessity, to do so. It should 
always be determined on in a formal Consultation with persons of 
ripe judgment, and enlarged clinical experience and knowledge. 
Where the necessity for removing the accumulation exists, it is, I 
repeat, easy to effect the removal. But I find I am lapsing in- 
sensibly into an obstetrical topic, and shall, therefore, cease to 
discuss it here, in hopes of presenting it at fuller detail, in my work 
on Midwifery ; and as I have now treated, tant Men que mal, on 
all the particular maladies of the womb, I shall close this letter, in 
order to take up some of the questions, as to diseases of the uterine 
appendages, as they are called. It would be far truer to call 
them the reproductive organs, for I am always of the opinion 
announced in an early letter of this series, that the stroma of ova- 
ries is the true sexual tissue of females; in fact, that stroma is 
sex for them. C. D. M. 



LETTER XXV. 

Gentlemen: — I have now to offer you some remarks upon the 
diseases of the ovaries ; and I wish that in doing so I could feel 
that the study and treatment of such affections had enabled us to 



300 OVARIAN DISEASE. 

give to the medical student clearer views as to the origin and 
early detection and control of such maladies, than those which the 
labors of the numerous writers have opened up to us on these 
subjects. I am persuaded, however, that our knowledge of the 
disorders of these most important organs is vague, and that the 
most serious of their maladies are of a nature so insidious, as to 
allow them to become considerably advanced and firmly estab- 
lished, long before they are detected by the pain or inconvenience 
or interrupted function to which they give rise. 

The ovaries are the reproductive organs, and they are endowed 
with a life-power that is variable in its operation, alternately tor- 
pid or quiescent, and most highly excited ; pale, oligemic, or red 
and hypersemic; so that the life-power does not act steadily and 
continuously, or in one even tenor, but is diminished and aug- 
mented by turns, exposing the texture to the multitudinous acci- 
dents that are ever ready to happen in tissues or organs of an 
unequable rate of vital function. 

One or other of the ovaries matures an ovule in the Graafian 
follicle every twenty-eight days, and discharges the egglet, either 
into the fimbria of the Fallopian tube, or into the peritoneal sac ; 
and this, with the greatest regularity in all healthy women that 
menstruate. Each of the ovaries contains fifteen or twenty of 
these Graafian follicles, of various sizes, from the bigness of a 
mustard seed to that of a pea. The smallest ones are generally to 
be found buried deep in the substance of the stroma ; while the 
larger and more mature ones are to be seen nearer the surface of 
the organ, and even rising above its surface in segments of spheres 
more or less considerable, as the cell is more or less prepared for 
the act of ovi-posit. 

Seeing that only one of the Graafian cells is matured at once, 
as a general rule, and that the later days of its ripening process 
are those in which the process goes on most rapidly, we may well 
conceive that such greater celerity of development takes place in 
consequence of a greater activity of the vital processes concerned 
in it. In fact, if we examine such a rapidly developing cell and 
germ in the body of a person who has perished during such act, 
we find the necrologic proofs of that extraordinary excitement. 
These proofs are seen in the highly injected state of the portion of 
the ovary immediately in contact with and circumjacent to the 
swelling follicle, where numerous arterioles and venules may be 



OVARIAN DISEASE. 301 

observed with the naked eye, and more plainly with a lens, sur- 
rounding and burying the growing cellule among a mass of blood- 
vessels. 

It is also presumable that the nerves of a part bathed in this 
manner with a luxuriant circulation, will be in like 'manner in a 
hyperaesthesic state; and hence that the life-force in the said 
part is in a highly exalted condition. 

Whenever you shall examine an ovary, under these circum- 
stances, I doubt not you will find the state of the case as I have 
represented it, and I can but perceive in it a close analogy to what 
happens during the last stages of dentition, as to the gum over 
a growing tooth. The gum in such state becomes swollen, suc- 
culent, sensitive, and painful. In like manner, I suppose, the 
stroma of the entire ovary may become engorged, swollen, red, 
and, in some instances, sensitive and painful. But the Graafian 
cell having become perfectly mature, opens by a sort of hila or 
rather porule, in order to allow the yelk to escape, and the crypt 
left upon its escape, fills with coagulated blood, while the edge of 
the pore is granulating and bloody, and at last heals over. In 
process of time the coagulum left within the crypt, and the vitel- 
lary matter secreted on the exterior surface of the inner concentric 
spherule of the cyst to constitute the corpus luteum, are both ab- 
sorbed, leaving the surface of the ovary indented with its puckered 
cicatrix, the mark of the last menstruation. If an advancing tooth 
may excite such maladies as are attributed to dentition in chil- 
dren, what must be the extent and power of complication of the 
ovary in the monthly act of eliminating the ovulum! 

A monthly, or bi-mensual repetition of this process, continued 
for years, is in some women followed by diseased or morbid life 
in the ovarium ; and we have no cause to wonder if a delicate 
and important organ should be found to succumb to such violent 
revulsions of its physiological action, repeated for months and 
years in succession. I should think we have greater reason for 
surprise at the rarity than at the frequency of the rise of ovarian 
diseases under this view of the condition of those organs. 

Besides the above-mentioned causes of liability to the superin- 
duction of morbid states of ovarian health, we ought to take into 
consideration the state of the ovaries in gestation, a state in which 
both their innervation and circulation may be supposed to be sub- 
jects of considerable modifications. Labor, too, and the lying-in 



302 OVARIAN DISEASE. 

state may be supposed to bring them into no little hazard of a 
change in their life-action. 

There are certainly many women to be met with who complain 
of ovaric pain during the menstrua — as they are frequently found 
to indicate, not the uterus, but the left or the right ovarium, as 
the seat of the distressing sensations of painful menstruation. 

The ovaria are occasionally the seats of ovaritis in an acute 
form, betrayed by pain in the region of the organ, and demon- 
strated by purulent disorganization after death; and inferentially, 
by collections of pus which discharge themselves at the groin or 
above it, with recovery of the patient. 

It is probable, as Madame Boivin states, that acute inflamma- 
tion of the ovary, in the non-gravid state, has rarely been observed, 
or rather, has rarely been with clearness made out ; and yet, as 
I have met with many samples of very distressing pain and ten- 
derness in the region of the organ, connected with painful and 
hysterical menstruations, I deem I had good cause to suppose the 
ovaries were actually in a state fit to be called ovaritis. Very cer- 
tainly, many of the cases of puerperal metritis and peritonitis 
commence with pain in the iliac regions; and, where the case has 
proved fatal, dissection has revealed greater ravages in the ovary 
than elsewhere; and it is by no means rare to find the organ 
filled with pus, or converted by the inflammation into a mass of 
softened tissue, which had undergone the process of ramollisse- 
ment, one of the results of inflammation in this special tissue. I 
regard the following case as one arising from acute ovaritis. 

I had for a long time charge of the health of a lady here, who 
at her mensual periods suffered the most terrible paroxysms of 
hysteria, during which she experienced such distress in the 
regions of the ovaria, as to cause her to scream and to make the 
most violent complaints. She recovered of her dysmenorrhoea and 
gave birth to two children, the second one about two years after 
the eldest. Subsequently to the second confinement, she disco- 
vered a small floating tumor in the left flank, which I ascertained 
to be an enlarged ovary. That tumor may have been three and 
a half by two inches in diameter, and for the last four years has 
not sensibly increased in size. The catamenia are regular and 
no longer painful, and she uses great precautions as to exercise, 
diet, dress, &c, at the mensual periods, which have thus passed 
over her without seeming to aggravate the tendency of the ovary 
to grow. 



OVARIAN DISEASE. 303 

When an ovary has become the seat of a hypertrophic, or of 
a heterologue development, it probably ceases to produce and 
evolve germs, but it is still liable to the periodical augmentation 
of the life-action, as propagated from the healthy ovary to the 
womb, and from the womb to the diseased ovary. If this be so, 
then the most hazardous period for the female with a diseased 
ovary, especially in the early stages of such diseases, ought to be 
esteemed the menstrual period ; hazardous, I say, as to the danger 
of increasing the propensity to morbid development, not hazard- 
ous as imminently dangerous to the life of the woman. I trust 
that you will reflect upon views of this sort, when you come to 
give advice under such circumstances, and institute such a course 
of treatment and management of the health as may enable the 
woman more safely to pass these mensual crises. 

In a case of acute ovaritis, attended with constitutional disturb- 
ance in the form of fever, and with pain in the region of the ova- 
rium, you would resort to venesection and leeches, or cups to the 
iliac region, to stupes or cataplasms, to the obtaining a soluble 
state of the bowels, and the use of tartar of antimony and potash, 
or Dover's powder with recumbent rest. 

A few years ago, I opened the body of an elderly woman, who 
died with an immense collection of water in the abdomen. The 
fluid amounted to several gallons, and after it had been removed, I 
continued the incision from the sternum to the pubis, and when 
I had finished the incision, and, with the medical friend who was 
with me, looked into the cavity, we were both for some time very 
much astonished to behold only a smooth muco-serous surface in 
the cavity, and we looked for some time in vain to find any liver, 
or stomach, or alimentary canal. It seemed that we were exa- 
mining an abdomen from which all the viscera had been care- 
fully removed. I was greatly astonished, and quite at a loss 
what to think of the case, or imagine what had become of the 
abdominal viscera, since the line of the spinal column was strongly 
drawn at the back of the cavity we were inspecting, and we 
seemed to look quite up into the empty concave of the dia- 
phragm. At length, in examining the cut edge of the incision, 
I saw that we were looking into an empty cyst, whose edge was 
there to be seen, and the outer superficies of which was adherent 
to the peritoneum. The cyst adhered pretty firmly everywhere, 
but it was cleavable, and I detached it completely, discovering 
the atrophied organs behind and below it, firmly compressed against 



W 



304 OVARIAN DISEASE. 

the back part of the abdomen. I have no doubt, this cyst held 
more than a thousand ounces of serum, probably twelve hundred. 
There was at the lower part of it a small solid or hardened por- 
tion, which was the altered remnant of the left ovary, all the rest 
of the cyst having been developed out of that body. I gave the 
specimen to Dr. Horner, who preserves it still, I believe, in the 
Museum of the University of Pennsylvania. It was the largest 
single cyst I have ever met with. 

Now, gentlemen, what was this cyst? It was certainly no 
longer an ovary, but a new tissue, heterologue, formed on the 
generic basis of a true ovary, and commencing, perhaps, as a 
Graafian cell, which, instead of bursting to discharge its ovulum, 
continued to fill and to strengthen itself, appropriating to the ex- 
tension of its heterologue walls all the nutritive results of the ova- 
ric circulation and innervation. 

It was a case of encysted dropsy of the belly. The cyst w T as 
an altered ovary. It was a single cyst. 

It does not always happen that the ovary, in developing itself 
out of, and beyond its generic form, assumes the nature of a 
single cyst, like the one above mentioned. It more commonly, 
I think, consists of much solid interstitial material, containing 
within it cells of various sizes, from the magnitude of a walnut to 
that of a child's head, and in these instances the fluid is ropy or 
albuminous, and sometimes almost as thick as melted calves'-foot 
jelly or glue. 

In some of the samples there is a great bunch of solid material 
lying partly within and partly above the plane of the superior 
strait, with one vast cyst holding 800 or 1000 ounces of fluid, 
that fill out *and distend the belly as a fluctuating mass, like a 
common ascites. 

If you do not see the patient from an early stage of the disor- 
der, nor until the abdomen has become very tense from the vast- 
ness of the collection, you will scarcely be able to make a good 
diagnosis of the tumor, since the hardness and resistance of the 
belly will not admit of your fingers indenting it sufficiently far or 
deep to make out the existence, much less the size and form of 
the more solid masses or portions of the altered ovarium. It is not 
until the woman has been tapped that the relaxation of the ab- 
dominal walls permits the palps of the fingers to estimate the ex- 
istence, and size, and forms of the solid portions of such tumors. 
Hence, when you shall be invited to give your opinion in a case 



OVARIAN DISEASE. 305 

of the sort, as to its nature, as being ascitic or cystiform, you will 
be unable to answer positively the question ; or, if you do answer 
positively, you will do so at the risk of compromising your own 
reputation, and injuring that of your brethren. You have no 
occasion to hesitate in such a case. If the means of discrimina- 
tion are not at your command, why should you not say so. If 
you owe a thousand dollars and have not the money, you would 
say so. If you cannot tell what is the nature of a tumor or a col- 
lection, are you afraid somebody else will know better, and thus 
discredit you? Let him know better if he can; but he cannot. 
If you cannot touch the altered and solid masses, either by the 
vaginal or the external exploration, how can he do it? — If you 
cannot extract a clear history of the formative stages, how can he 
do it? If you can estimate the fluctuation, what can he do more ? 
Let him make his declaration — he does it at his peril, not yours. 
There are some that will be ready to make it, hit or miss — with 
all my heart, let them hit or miss. If they hit, they are like 
rockets that go up with a whiz and a great light — if they miss, 
they are like the rocket stick, which falls, not sweet, to the 
ground. There are two ways to hurt the profession which any 
one may perpend. One is to act immorally and unconscientious^, 
and the other is to make mistakes in diagnosis, treatment, and 
prognosis; both serve with equal force to bring physicians, as a 
body, into disgrace. The whole herd of quack doctors and char- 
latans, who perform such inexpressible wonders of folly in diag- 
nosis, treatment, and prognosis, are sustained upon the shoul- 
ders of medicine; for they could not exist in an enlightened 
community but upon the force of that confidence which mankind 
cannot withhold from medical science ; but which is so far pecu- 
liar, and, therein beyond the reach of the esoteric classes, that 
they cannot discriminate between the true physician and the un- 
learned and bold pretender to medical science. Hence we, that 
is the physicians, who are the conservators of medicine, and her 
representatives in the world, bear all the odium of every vile 
quackery and charlatanism. 

These encysted dropsies are often very chronical in their move- 
ments. I know a lady who has worn one for more than twenty 
years — it has never been tapped, and is not larger now than it 
was fifteen years ago. Another lady here, with a very large en- 
cysted dropsy, gave birth to several of her children after the cyst 
20 



306 OVARIAN DISEASE. 

had become very large indeed. She ceased to bear children, after 
having been swollen for fifteen years; and at length, the weight 
and tension becoming insupportable, she was tapped with great 
relief, and without any inflammatory result or any inconvenience. 
In about five years the sac was insufferably full again, and she 
was tapped a second time, discharging a vast quantity of fluid. 
She recovered apparently, but about twelve days afterwards rode 
twenty miles to a funeral. Soon after reaching the country place, 
she was seized with symptoms of peritoneal fever, from which she 
barely escaped. The sac has again filled. You see how chronic 
the case is. She has not been tapped for near six years. 

A lady here had a very enormous encysted dropsy. She w^as 
never tapped. After wearing it for many years, the size of the 
abdomen diminished, and more and more rapidly, until every ves- 
tige of the malady had vanished, and she now enjoys good 
health. 

I saw a patient in the Pennsylvania Hospital with ovarian 
dropsy. The tumour gradually disappeared and was followed by 
crural phlebitis of the left leg, or milk leg. 

Now the question arises as to the quo-modo of these dispari- 
tions of ovaric dropsy. You will not, I presume, imagine it to be 
possible that the collection within the cyst, a collection that has 
existed within it for a series of years, could be taken up by the 
absorbents of the sac, and carried off as in ordinary cases of ab- 
sorption. You should recollect that the sac is only like a true organ, 
not a true one; it is not in truth a human tissue, or a tissue of a 
mammiferous creature ; it is something different from any of the 
organic materials that enter into the composition of such a being; 
it is a monstrosity by excess, a case in Teratology. Such a cyst, 
though it has arteries, and capillaries, and veins, and nerves, has 
■ hem in a new and ungeneric way. It cannot be supposed to 
possess the just proportion of absorbing apparatus; and it cannot, 
therefore, absorb the products of its exbalent or secretory elements. 
But still, such tumors do disappear now and then. 

Without pretending to dogmatise on the subject, I may be 
allowed, I hope, to say, that in all such cases of disparition of the 
collection, I have supposed that an aperture being made in the 
cyst, the fluid has passed into the natural sac of the peritoneum, 
and being there subject to the action of a true natural absorbent 
apparatus, has been taken up and carried away, leaving the sac 



OVARIAN DISEASE. 307 

itself to collapse and shrivel, and sink back towards the pelvis, 
where it might exist during a long lifetime, an innocuous mass 
that never fills again, and whose inner parietes perhaps become 
coherent from long quiet contact. In the case of adhesion of the 
cyst to the peritoneum, in the elderly woman that I mentioned 
a little while ago, the cohesion was equal in force to that of a full 
developed placenta to the uterine paries, or equal to the cohesion 
of the skin of a ripe orange to the fruit. 

That such apertures and leakages of the ovarian cyst into the 
peritoneal sac do take place, has been proved by Dr. Bennet, in 
his account of a case referred to by Prof. Simpson in his pamphlet 
on Ovariotomy, p. 9. Such a leakage, to a greater or less ex- 
tent, must, I think, always follow the tapping of an ovarian cyst, 
when the cyst does not adhere. It is not improbable that the 
danger of the operation of tapping, in these encysted dropsies, 
arises in the main from the irritating influence of the contents of 
the cyst effused suddenly into the peritoneal cavity, upon with- 
drawing the canula. When the cyst opens spontaneously, and 
the leakage is small and gradual, probably the inflaming tend- 
ency is less. Possibly the tension hinders inflammation. This, 
however, is mere hypothesis, although it is certain that a great 
many of those persons speedily perish who are for the first time 
subjected to the paracentesis. If my hypothesis is correctly 
founded, it would seem to be less dangerous to tap in the com- 
pound dropsy of ascites and encysted collections, than where the 
sac is still unbroken ; as the peritoneum that had learned to tole- 
rate the leakage, would not suffer from a leakage made by the 
trocar. Certain I am, that where a female has been once tapped 
for an encysted collection, and escaped death, she is but little 
liable to perish from subsequent operations ; such at least has been 
the result of all my experience on this head. 

Dr. Lee, " Tumors of the Uterus" p. 175, has furnished some 
highly interesting information on the subject of tapping these 
cysts. He avers, that where the collection exists in a single sac 
or unilocular cyst, the danger is much less than in the cases 
where the collection is contained in many different cells, or cham- 
bers of the tumour — and this I think is to be expected ; inas- 
much as the multilocular cysts are always of a more massive and 
solid material, and afford greater basis for inflammation and its pro- 
ducts ; whereas the unilocular cyst is like a vast bladder, possessed 



308 OVARIAN DISEASE. 

of scarcely an organization, and not so readily obedient to the 
provocatives to inflammation ; or if inflamed, not admitting of such 
vast masses of inflamed material. 

Dr. Lee has made some curious, interesting, and valuable 
researches on the effects of these tappings. He has collected 
forty-six cases wherein the effects were observed, eight of them 
by himself, five by Dr. Ashwell, five by Dr. C. Smith, six by 
a London surgeon of high standing, and the remaining twenty- 
two taken from journals. Of these forty-six patients thirty- 
seven died, and nine recovered. Of the thirty-seven who died 
fifteen died within one month after the operation, at various 
periods from a few hours to the end of a month. Seventeen died 
by the expiration of two years, and five died in from three to 
fifteen years. Eighteen of the thirty-seven were tapped but once, 
the others more than once, say from twice to seventy-eight times. 
Dr. Lee furnishes also a table of twenty cases from Mr. Southam, 
from the Lond. Med. Gaz., Nov. 24, 1843. Of these twenty 
cases fourteen died within nine months, two within eighteen 
months, and the remaining four in several years, from four to 
nine. Dr. Lee gives, at page 180, another table, showing that 
of fifty-seven patients, from his own tables and Dr. Southam's 
combined, who died, twenty-four died after the first tapping, and 
all of the twenty-four within a period ranging from a few hours 
to eight months. 

I have made the above citations from Dr. Lee's work for you; 
I should much prefer that you consult the book for yourselves. 
I think the statements of the author highly useful, and am sure 
that they agree very nearly with my own observations. As to 
cure of dropsy of the cavities, or of ovarian dropsy by tapping, or 
after tapping, I have never met with an instance of such success. 

I trust that what has now been said, may serve to put you on 
your guard against an opinion, very prevalent in our profession, 
that paracentesis abdominis is a slight operation, that may be 
performed with safety to the patient. I have assuredly not ob- 
served it to be so, since I am under the impression, that of first 
tappings, of which I have been a witness, well nigh one-half have 
been speedily followed by the death of the subject from peritonitis, 
developed soon after the performance of it, and all ended fatally 
sooner or later, save the case above-mentioned. 

These encysted dropsies occur in young and unmarried females. 



OVARIAN DISEASE. 309 

I now remember seven cases of this kind that have fallen under 
my immediate notice. I have certainly seen a much larger num- 
ber of them, and a great many in married women. 

You will in vain attempt to cure them by diuretics. Diuretics 
and hydragogues can not enter into competition with the powers 
concerned in making and augmenting the fluid contents of the 
sac. It is wrong, therefore, to assist the disease in uprooting the 
foundations of the constitution by acting on it with drugs, most 
of which are exceedingly enervating in their influence on the 
stomach and bowels. In the conduct of all such chronical, long 
continuing maladies, you ought never to lose sight of the liability 
of those important organs, to be injuriously deranged by the pro- 
tracted employment of remedies addressed either directly to them 
or through them to the whole constitution of the patient. 

We have hitherto spoken chiefly of the unilocular cyst con- 
structed out of the ovarium. It is necessary to observe that some 
of the ovarian tumors are solid degenerations of ovaric tissue, 
enormously increased in size and totally destitute of the anatomical 
characters and physiological powers of the stroma. Such a tumor 
when felt, through the abdominal parietes, is found to be hard, 
resisting, presenting a defined outline of an irregular figure ; be- 
cause the surface of the tumor is broken by large lumps or pro- 
tuberances divided by sulci of various length and depth. Some of 
these tumors, when cut open, present a sort of heematomous or cere- 
briform appearance as to color. Others are filled with numerous 
cells or loculi, containing viscous or serous effusions, and sometimes 
pus or puriform excretions. The loculi are of various sizes and 
shapes, some communicating together, and others entirely isolated. 
The tumors are found of a size to fill up the cavity of the belly, so 
as to make it as large as that of a woman in an advanced stage of 
gestation. In many of the samples, adhesions of the peritoneal 
surfaces of the tumor to that of the intestines, or abdominal walls, 
are observed, the results of ancient or recent, or of repeated attacks 
of peritonitis. But why describe the peculiar forms and aspects 
of tumors which embrace within their precincts, the possible 
modifications of the cellular, vascular or fibrous elements of the 
altered organ ; modifications so infinitely varied and mixed, that 
the usual and clearest description given of them in a necrological 
account is a "mass of disease?" 

Tumors of this fashion, large as a man's head or larger, draw 



310 OVARIAN DISEASE. 

nearly the whole of their support from one ovaric artery running 
off from the aorta, or emulgent, and reaching the points of distri- 
bution after a long tractus, while its strange vitality and econo- 
mic connection are maintained chiefly by the accompanying 
spermatic nerve. It is clearly a case of physical sin and abso- 
lute rebellion against the authority and laws of the economy, so 
that it can neither be recovered nor subdued. What idleness, if 
not what folly, to give medicines! Medicines for a tumor! 
Give medicines for a swelling, for a disease, but not for a tumor. 
"What, then! Shall we not treat such cases?" Yes, surely; 
they require treatment ; they admit of it ; and the patient is bene- 
fitted and even preserved by it; but the tumor is unaffected, it 
pursues the even tenor of its way indifferent to the condition of 
the woman upon whose person it has attached itself and on whom 
it preys. I have before said, that you cannot make a very certain 
prognosis of it, for you cannot know whether it will grow con- 
tinuously larger, or whether, becoming the seat of a disorganizing 
activity, it softens and deliquesces, or suppurates within the ab- 
domen, pouring its fatal products into the peritoneal sac ; or whe- 
ther, preserving for years its quasi organization, and losing the 
power of increase from atrophy of the most distal and attenuated 
branches of its vessel and nerve of supply, it stops at a term, and 
continues there for years without apparent change. For exam- 
ple, there is a lady here of whose health I have had principally 
the charge for about eighteen years. She is at present near sixty 
years of age. For eight years before I became acquainted with 
her, she had suffered from an enlargement of the right ovarium. 
The tension and pressure, and intrusion, gave her at times much 
pain in the right inferior portion of the abdomen ; and at different 
times since my being first called to her, she has had attacks 
which I regard as peritonitis, brought on by the pressure and 
friction of the mass. These attacks have pretty readily yielded 
to the appropriate antiphlogistic treatment, consisting mainly in 
copious depletion and recumbent rest. I have lately examined 
the state of the tumor, which I find scarcely changed in the course 
of eighteen years, except, perhaps, in a slight increase of its 
magnitude. It has never exerted the least influence on the nutri- 
tion of my patient, who is a robust, ruddy faced, even fat woman, 
who walks freely in the streets on affairs of business or amuse- 
ment; and there is good reason to suppose, from her present state, 



OVARIAN DISEASE. 311 

that she will attain to an age not the least curtailed by a tumor of 
the ovary as large as a man's head, and so firm in its resistance, 
as to yield not at all to pressure, and afford no reason to suspect 
the presence of fluid within it. In all these eighteen years I have 
never given my patient any medicine with a view to act upon the 
tumor. I have bled her many times for the accidents arising from 
its pressure, and administered many doses of medicine with a 
view to obviate the effects of those accidents. Had I been occu- 
pied always with the preposterous idea of curing her tumor, she 
would have taken physic enough to establish a Chestnut street 
apothecary, and cui bono, I pray, save to the apothecary? 

These solid tumors nobody, in his senses, would propose to 
tap ; and, you see, I insist there is no medicine can do them good. 
What then is to be done? Can ovarian tumors be cut out? 
Yes, they have been cut out, and the patients, in certain instances, 
have recovered. 

As to the question of cutting out the ovarian tumor, it is a 
question in surgery which, as an Accoucheur and a Practitioner 
of medicine, it may be supposed that I have no special claim to 
speak to. Nevertheless, I have an undeniable right to lay before 
you a statement of the motives that should govern me in any 
question as to the performance of this operation on a patient of 
mine ; and, I trust, that in entertaining the opinions I do on this 
topic, I may be held to do so not without due respect to the enter- 
prising and courageous surgeons who have advocated the extir- 
pation of the diseased ovary. 

As to surgical operations in general, I hold to the sentiment 
that prevails very generally in this quarter among surgical gen- 
tlemen of the highest standing, that it is a dire necessity that 
compels a resort to the bistoury, and that the fact of a surgical 
operation being necessary in any case, is a reproach to medicine. 
This is a noble sentiment, and one that deserves to be upheld and 
propagated far and wide by all the true lovers of our divine art. 
It has, in a prime degree, governed the conduct of the surgeons 
of the Pennsylvania Hospital these many years, and is one of the 
titles to that general confidence that has been given so steadily 
to that admirable establishment. 

Doubtless, in the history of surgery, many cases are to be found 
of operations performed without necessity. That this is the case 
no one can deny, who will refer to the examples of the Cesarian 



312 OVARIAN DISEASE. 

and Sigaultian sections, not to allude to many others that are on 
the files of cases. But as "life is short, while art is long, occasion 
fleeting, and judgment difficult," to use the language of the first 
aphorism, there must have been, and must still exist many cases 
where the actual circumstances cannot admit of the exercise of a 
perfect judgment, so that operations are performed under the 
spur of a seeming necessity. Many a limb, for example, is sacri- 
ficed by the catlin and saw that might be saved by the use of a 
more sober and cautious judgment. 

In regard to the Cesarian section, which is, perhaps, the most 
important of surgical operations, much is to be left to the judgment 
and conscience of the surgeon and the gentlemen of the consulta- 
tion, since even at the present day, it is not determined what pre- 
cise degree of reduction of the pelvic diameters makes the opera- 
tion not lawful only, but indispensable as an act of professional 
duty and charity. 

For a medical man called to and placed in charge of a labor 
with deformed pelvis, there is a most solemn obligation resting on 
him to protect the lives of both the mother and the child, and if he 
be truly competent to the exercise of that wise discrimination and 
judgment that alone are suitable to such great and trying occa- 
sions, I can clearly perceive that, with the calmest and most un- 
troubled conscience, he may recommend and perform the Cesarian 
operation, which he knows will result in the death of the mother 
in about one-half of the cases in which it is performed ; and I deem 
that where he has both counseled and performed the operation, he 
might look with an undisturbed aspect upon the body of the vic- 
tim he vainly strove to save. Such a person being in charge of 
the case, cannot escape from the stringent necessity of acting in it. 
He cannot go out of the lying-in chamber saying that there is a 
chance for recovery by the Cesarian section, but declining to do it. 

Not so in any tumor or other malady developed by diseased ac- 
tion. For example, in a cancerous breast, a man may refuse or 
consent to perform the operation for its ablation ; but he cannot 
refuse the operation of lithotripsy, or that of cutting for the stone 
in the bladder in a case proper for it ; in the case of the cancer- 
ous breast he may decline or consent, according to his opinion of 
the risk from the operation or of a return of the disease. In the 
case of the stone he cannot refuse, on account of the urgent dis- 
tress that appeals to him for relief. 



OVARIAN DISEASE. 313 

In forceps operations, and embryotomy operations in midwifery, 
I do not understand how any one can have the right to decline in- 
terfering where the safety of the mother or that of the child clearly 
requires his intervention. In such cases as stone in the bladder, 
in amputations for railroad accidents, for white swellings, &c. &c, 
the requirements are instant and pressing, and the exigency admits 
of no refusal nor delay. It is a hard and dire necessity then that 
makes the act of the surgeon not only excusable, but charitable, 
and even noble. Any surgical operation founded on other prin- 
ciples, — on some cold and calculating computation of benefits pos- 
sible, I regard as of doubtful propriety ; and I believe that no 
surgeon ought to operate where he can escape the duress that 
binds him to do his cruel kindness. 

I will add, that in the Cesarian operation, there is but one rule 
for the conscience of the physician, and that rule has reference to 
the mother. The Cesarian operation is never to be performed for 
the sake of the child. If a man perform the operation for the sake 
of the child's safety, and the mother perishes, who might have 
been saved by some other method, I see not how his conscience 
can ever recover its composure and complacency. No! Whenever 
you are tempted to perform the Cesarian operation, let it be done 
from a conviction, and a clear one, too, that to deliver per vias is 
equally hazardous with the section. When you can come to this 
intelligent conviction, then you can enjoy the high gratification 
of hoping to save both the mother and her offspring. 

Having said so much, it is clear that I am opposed to the ope- 
ration for extirpating the diseased ovary. The ground of my ob- 
jection lies in that principle of surgery, which I hold to be one of 
its highest principles, that there can be no duress, no binding 
obligation to perform it, and that the surgeon's conscience may 
be at peace, though he refuse and the patient perish by the pro- 
gress of the malady. 

I have read with great pleasure Professor Simpson's remarks 
in favor of ovariotomy, in a pamphlet, for a copy of which I am 
indebted to his politeness. I admit the considerable force of mam 
of the arguments arrayed in Professor Simpson's publication, but 
I see no parity in the duress of the surgeon who decides upon an 
ovariotomy, and that of the surgeon who performs the operation 
for the stone, or an amputation, or the ligature of an important 
vessel, &c, which he dare not refuse to perform, whereas no 



314 OVARIAN DISEASE. 

such urgent, imminent, and definite necessity can ever be sup- 
posed of an ovariotomy operation. 

In the one case, the surgeon resorts to the operation under 
compulsion of an imminent and pressing danger; in the other, he 
takes his instrument in his hand under the dictation of a cold 
calculation of chances as to a human life. Now, who, I pray, 
has the right to calculate as to the value of a man's life, even for 
an hour, much more for a week, a month, a year, or a quarter of 
of a century ! 

I am opposed then to the operation of ovariotomy, and I am 
opposed to it on the grounds of objection I consider valid against 
all surgery that is not unavoidable. 

The ovariotomy operations are not unavoidable, since no one, 
I presume, would think of operating for a patient not remote from 
dissolution, and since in any case not menacing a speedy termi- 
nation of the life of the patient, the unavoidable necessity has not 
arrived. 

In a note that I added at the 415th page of the American edi- 
tion of Colomhafs Treatise on Diseases of Females, I stated that 
I fully concurred in opinion with M. Colombat, who disapproves 
of the ovariotomy operation, and that I look upon operations for 
the extirpation of diseased ovary, as not to be justified by any 
amount of success. There are certain medical facts that belong 
not to us as a body of physicians alone, but which enter into the 
common treasury of human knowledge, and no array of statistical 
results can ever, I imagine, change the nature of things. It is 
in the nature of things, that wounds, even small ones, of the great 
cavities are dangerous wounds, and a fortiori, wounds of vast 
dimensions, and wounds, too, requiring that other deep-seated 
parts should be cut away and vessels tied within those cavities, 
are so dangerous, by the common voice and consent of man- 
kind, that I should in vain endeavor to reconcile it to myself 
that I am bound to do such things, except under the duress and 
stringent necessity laid upon me by my position as physician or 
accoucheur. 

I have already shown you from Dr. Lee's work, how dangerous 
is the simple operation of a first tapping in ovarian tumors. The 
same valuable w T ork contains a table of 118 operations for the 
removal of the ovary with the results ; but Dr. Lee shows that the 
unsuccessful cases have not all been made known to the public, 



OVARIAN DISEASE. 315 

for Mr. Phillips informs him that he was aware of five other eases 
of which, at least, three were unsuccessful, and D. F. Bird men- 
tions several not made public, that would go to swell the list of 
fatalities. I shall not fatigue your patience by following the com- 
parative estimates of mortality in ovariotomy and other grave 
operations in surgery. What I have already stated as to my 
opinion, on the binding nature of the chirurgical duty in serious 
operations, may excuse me from giving you such trouble, for I 
hope I need take no further pains to show you that what you 
must do, and what you may prefer to do in the way of surgery, 
are categories wholly different from each other. 

Facts are the things that teach— and I shall close this letter by 
laying before you the Tabular View presented by Dr. T. S. Lee, 
who, I am sure, will not object to my using so great a liberty with 
his work, the more especially as it may assist in spreading further 
and wider the knowledge he has been at so great pains to collect, 
and make it both more public and useful at once. 

C. D. M, 



316 



DR. LEE'S TABLE 

















TABLE, by 


Dr. Lee. — 


A Table of all the known Operations 


No. 




Operator. 


bo 


Length 
of 


Adhesions 
or 


Error of 
Diagnosis 


Complica- 
tion with 


Character of the 
tumor. 


Cause of death. 




03 0) 




<J 


incision. 


not. 


or not. 


other dis- 
eases. 


cystic or not. 




1 
a2 


1809 


L'Aumonier 
Dr. M'Dowal 




4 in. 
9 in. 


None 






Abscess of the 

ovary after deliv ery , 

cyst. 

Cysts 




3 




Do 






Adhesions 


Not re- 
moved. 


Both ova- 
ries affect- 
ed. 


Cysts 




4 


1816 


Do 






None 






Scirrhus ovary 




5 


1817 


Do 






None 






Scirrhus ovary 




6 


1819 


Do 






Adhesions 






Cysts with bone 
and hair. 


Peritonitis 


67 




Dr. Chrismar, or 




Long 












8 
9 


1819 


Chrysmer 
Do 


47 


Long 
Long 


Adhesions 






Cartilaginous 

& cardaceous 

tumor. 


Gangrene of 
Intestines. 


.10 


1820 


Do 


38 




Adhesions 






Fibrous & cel- 
lular tumor. 




11 


1820 


Do 


38 




Adhesions 




Tubercular 

liver, scirrhus 

mesenteric 

glands. 


Lardaceous & 
cysts. 


Peritonitis & 
Gangrene. 


12 


1821 


Dr. N. Smith, 

(Connecticut) 


33 


3 in. 


Adhesions 






Cystic. 




13 




Do 




Unknown 




Not re- 
moved. 


Disease of 
the uterus. 


Uterine 

tumor. 




14 




Do 




Unknown 


Adhesions 


Not re- 
moved. 




Cyst. 




15 


1823 


Dr. A. G. Smith 


30 


Long 








Cyst. 




16 




Do 




Unknown 












17 




Do 




Unknown 










Secondary 
haemorrhage. 


18 




Do &M. M'Dowal 




Long 




No 

tumor. 




Conglomerat. 
Intestines. 




19 


1823 


Mr. Lizars 


27 


Long 




No 
tumor. 








20 


1825 


Do 


36 




None 




The other o- 
vary diseased. 


Ovarian tumor. 




21 


1825 


Do 


25 




Adhesions 






Ovarian tumor. 


Gangrene of 
the perito- 


22 




Do 


34 






Not re- 
moved. 




Solid and vas- 
cular tumor. 


neum. 


23 




M. Dzondi 




Unknown 








- 




24 




Galenzowski 


27 


Long, 5 in. 


Adhesions 


Not re- 
moved. 




Multilocular 
cyst. 




25 




Dr. Quittenbaum 




Long 













OF OVARIOTOMY. 

Tumors of the Uterus, pp. 264-71. 



317 



of Ovariotomy, from 1809 to 1846. 


Time of 








death 


Result. 


Remarks. 


References. 


after 








operation. 










Recovered. 




Edin. Med. Surg. Jour. vol. xviii. p. 
532. 




Recovered. 


Cyst opened, dirty gelatinous fluid withdrawn, 


American Jour, of Med. Sciences, 






and sac removed. Wound 3 in. to the left of 


from Eclectic Repertory, p. 261. 






rectus muscle. 


Jan. 1845. 




Recovered. 


Both ovaries affected, cysts opened, bloody and 
gelatinous matter escaped, adhesions to blad- 
der and uterus, incision in the same place. 
See note. 


Ibid. 




Recovered. 


Incision in linea alba. 


Ibid. 




Recovered. 


Profuse haemorrhage. 


Ibid. 


3d day 


Died. 


Incision on the left side. 


Ibid. 




Recovered. 




Monthly Jour, of For. Med. vol. iii. 




Died. 




p. 440. Phila. 1829. 


36 hours. 


Died. 


Extensive adhesions to colon, stomach, and pe- 
ritoneum ; one gallon of yellowish-green se- 
rum in the abdominal cavity. 


Ibid. 




Recovered. 


Afterwards became pregnant, 8 years after the 


Ibid. 






operation. 




36 hours. 


Died. 


Diseased and deformed from infancy, tumor 
varicose, pedicle 4 inches in thickness. As- 
cites. 


Ibid. 




Recovered. 


Emptied the cyst and removed it; it weighed 


Edin. Med. & Surg. Jour. vol. xviii. p. 






two or three ounces. 


532. (Amer.Med.Rec. vol.v.p. 124. 
also Dub. Jour, vol . xxv. 1844. p. 382.) 




Recovered. 


Uterus was the most voluminous part of tumor. 


Med. & Surg. Memoirs, bvN. Smith, 
edited by N. R. Smith, p". 231. 




Recovered. 


Sac emptied, but too adherent to be removed, 
slight peritonitis, sac and abdomen again 
filled. 


Ibid. 




Recovered. 


Emptied the cyst, drew out the sac, tied its 


North Amer. Med. Jour. Jan. 1826. 






pedicle, and removed it. 


New York Jour, of Med. Sept. 1843, 
p. 169. 




Recovered. 








Died. 


The animal ligature used, gave way prema- 
turely. 


Ibid. . 


42d day 


Died. 


The patient tapped herself 90 times. 


Ibid. 




Recovered. 


Deceived by great obesity and distended ful- 
ness of bowels. 


Lizars on Extraction of Ovary. 




Recovered. 


Some haemorrhage, other ovary diseased, but 

left. 
Tumor weighed 7 lbs. 


Ibid. 


2 or 3 


Died. 


Ibid. 


days 










Recovered. 




Ibid. 




Recovered. 


By incision, the use of tents, and subsequent 


North Amer. Jour, of Med. Science, 






extirpation of the mortified cyst. 


vol. xxxv. 1845. Atlee's Table. 




Recovered. 


Opened the tumor, tore up the cells, fixed it 


Jeafireson's Essay, Lond. Med Gaz. 






by ligature to the wound, and obtained a per- 


1844-5, p. SI. 






fect cure. 






Recovered. 




Philips' Tables, Med.-Chir. Trans. 
vol. xxvii. p. 672. 



318 



DR. LEE 7 S TABLE 





a 






Length 


Adhesions 


Error of 


Complica- 


Character of the 




No. 


is a 


Operator. 


be 


of 


or 


Diagnosis 


tion with 


tumor, 


Cause of death. 




a J; 




< 


incision. 


not. 


or not. 


other dis- 


cystic or not. 






Q £ 












eases. 






26 


1826 


Dr. Granville 




Long, 9j in- 


Adhesions 


Not re- 
moved. 




Cyst. 




27 


1827 


Do 


30 

40 
24 


Long, 9 in. 












28 


1826 


Dr. Martini 


Long, 9 in. 


Adhesions 


Not re- 




Cartilaginous tu- 


Haemorrhage 














moved. 




mor, with cysts. 




29 


1828 


Dr. Dieffenbach 


40 


Long 


Adhesions 


Not re- 
moved. 




Tumor highly 
vascular. 




30 


1829 


Dr. D. L. Rogers 


20 


Long 


Adhesions 






Cyst. 




c31 




A case in Frori- 
ep's Notizen. 
Anonymous. 


4S 


Long 


Adhesions 


Not re- 
moved. 




Cyst. 




32 




Dr. Ritter 


31 


Long 


None 






Cyst. 




33 


1830 


T. C. Warren 


40 


Long 


None 






Scirrhous 
tumor. 


Haemorrhage 


34 


1833 


Mr. Jeaffreson 


40 


Minor 
H in. 
Long, 


None 






Cyst. 




35 


1834 


Mr. King 


40 




No tumor 
















7 or 8 in. 












36 


1836 


Do 


37 


Minor 


None 






Cyst. 




37 




Do 




Minor 




Not rem. 




Omental tumor. 




38 


1836 


M. Dolhoff 


23 


Long 








Cyst. 


Peritonitis 


39 




Do 


27 


Long 


None 
Adhesions 


Not re- 
moved. 




Solid tumor. 




40 




Do 


2S 


Long 




Notumor 








41 


1836 


Mr. West 


45 


Short, 2 in. 


None 






Cyst. 




42 




Do 


23 


Short 








Cyst. 




43 




Do 


24 


Short 






Shattered 
constituti'n 


Cyst. 


Sunk after 
operation. 


44 




Do 


40 


Short 


Adhesions 


Not re- 
moved. 




Cyst. 




45 




Mr. Hargraves 


40 


Short 


Adhesions 


Not rem. 




Multilocularcyst 




46 


1840 


Mr. B. Phillips 


21 


Short 


None 




Ulceration of 
the bowels of 
long standing. 


Cyst. 


Inflammation of 

mucous coats of 

the bowels. 


47 


1841 


Dr. Stilling 


22 


Long, 6 in. 


None 








Haemorrhage 


d48 


1842 


Dr. C.Clay 


46 


Long 


Adhesions 






Solid & fluid. 




49 


1842 


Do 


5? 


Long, 14 in. 


Ext.Adhes. 






Cysts. 




50 


1842 


Do 


39 


Long, 28 in. 


do 






Cysts. 




51 


1843 


Do 


47 


Long, 16 in. 


do 


Not rem. 




Anomalous. 


Inflammation 


e52 


1843 


Do 


Vo 


Long, 14 in. 






Disease of 
the uterus. 


Fleshy tumor 
of uterus. 


Haemorrhage 


53 


1843 


Do 


40 


Long, 14 in. 


Ext.Adhes. 






Cyst. 


Haemorrhage 


54 


1S43 


Do 


22 


Long, 14 in. 


Adhesions 






Cysts. 




55 


1843 


Do 


40 


Long,14in. 


None 






Cysts. 


Inflammation 


56 


1843 


Do 


43 


Long, 14 in. 'Ext.Adhes, 






Cysts. 




57 


1843 


Do 


59 


Long, 16 in. Ext.Adhes. 






Cysts. 


Exhaustion 


58 


1843 


Do 


45 


Lon<r,14 in. 








Hydatid. 




59 


1843 


Do 


OS 


Long, 8 in. 








Pelvic tumor. 




60 


1843 


Do 




Long, 16 in. Ext.Adhes. 






Tumor. 




£61 


1844 


Do 


49 


Long 






Disease of 
uterus. 


Uterine tumor. 




62 


1845 


Do 


35 


Long,14in. 


None 






Cystic with 
solid matter. 




63 


1846 


Do 


51 


Long 


None 






Cystic. 


: 



OF OVARIOTOMY. 



319 



: Time of 








• death 


Result. 


Remarks. 


References. 


after 








operation. 










Recovered. 


Very adherent, incised largely and carefully 


Churchill's Notes. Dubl. Jour. vol. 






emptied. 


xxv. 1844, p. 383. 


3 days 


Died. 


Death attributed to venesection, under the false 
alarm of peritonitis. 


Ibid. & Med. Gaz. Jan. 13, 1843. 


36 hours 


Died. 


Inseparably connected with the brim of the pel- 
vis ; removed a sacculated portion of it. 


Churchill's Notes. Rust's Magazine. 




Recovered. 


Startled at the size of the base of the tumor, 


Amer. Jour, of Med. Science, vol. v. 






and flow of blood on puncturing it. Opera- 


1829-30. Rust's Mag. 






tion abandoned on account of adhesions. 






Recovered. Cyst unintentionally opened, emptied, relieved 


New York Med. & Phy. Jour. Jan. 






of very extensive adhesions, and removed. 


1830, p. 285. Amer. Journ.ofMed. 
Science, vol. v. 1829-30, p. 549. 


6th day 


Died. 


Had been tapped 5 times in 6 months, had a 


Churchill's Essay. From Froriep's 






broad base, and not removable from the os 


Notizen. 






innominatum. 






Recovered. 


First tapped, and two weeks after removed the 
ovary. 


Churchill's Essay. 


On the 


Died. 


Ligature slipped. 


Surg. Obs. on Tumors, by T. C. War- 


table 






ren, p. 590. 




Recovered. 


Cyst emptied of 27 pints, drawn out and re- 
moved. 


Trans.Prov.Med.Assoc.vol.v.p.239. 




Recovered. 




Churchill's Essay. 




Recovered. 


Cyst, with a solid base, 27 pints of fluid evacu- 
ated, sac drawn out and excised below the 

ligature. 


Lancet, Jan. 21, 1837, p. 586. 




Recovered. 




Med.-Chir. Trans, vol. xxvii. p. 473. 


2 days 


Died. 


Cyst emptied of 15 pints and removed. 


Trans. Prov. Med. Assoc. vol. v. p. 245. 


8 hours 


Died. 


Declined removing it, being solid and fixed in 
the pelvis by adhesions. 


Churchill's Essay. 




Recovered. 




Ibid. 




Recovered. 


Cyst emptied of 20 pints, drawn out and removed . 
Simple cyst, Prep, in St. Bartholomew's Mu- 


Lancet, Nov. 25, 1837, p. 307. 




Recovered. 
Died. 


Cyst emptied of 24 pints and removed. 


Lancet, Oct. 14, 1839. 
Ibid. 




Recovered. 


Not removed on account of adhesions, had to be 
tapped afterwards. 


Lond. Med. Gaz. 1844-5, p. 86. 




Recovered. 


Not removed on account of adhesions. 


Ibid. 


6th day 


Died. 


Died of the disease, not the operation. 


Ibid. Oct. 9, 1840. 




Died. 




Brit. & For. Rev. Churchill's Essay. 




Recovered. 


Incision 27 inches, tumor 28 lbs. 


Medical Times, No. 160. 




Recovered. 


Extensive adhesions, tumor 24 lbs. 


Ibid. No. 161. 




Recovered. 


Tumor 73 lbs., very extensive adhesions. 


Ibid. No. 162. 


7th day 


Died. 




Ibid. No. 163. 


Immedi- 


Died. 


Tumor and entire uterus, except the cervix, re- 


Ibid. No. 164. 


ately. 




moved. 




36 hours 


Died. 


Ovarian tumor 26 lbs. 


Churchill's Essay. 




Recovered. 


Tumor 26 lbs. 


Ibid. 


38 hours 


Died. 




Ibid. 




Recovered. 


Tumor 31 lbs. 


Ibid. 


32 hours 


Died. 


Tumor 54 lbs. 


Ibid. 




Recovered. 




Ibid. 


10th day 


Died. 


Dr. Clay says she recovered from the operation. 


Ibid. 




Recovered. 


Tumor weighed 26 lbs. 


Ibid. 


3 weeks 


Died. 


Uterus and ovaries were removed. 


Ibid. 




Recovered. 


Solid tumor 9 lbs., fluid and solid 53 lbs., evacu- 
ated the cysts before extraction, patient re- 
turned into Wales 15 days afterwards, subject 
to the disease 10 or 12 years. 


Med. Times, No. 282, Feb. 15, 1845. 




Recovered. 


Well 17 days after the operation. 


Med. Times, No. 333, Feb. 14, 1S46. 



320 



DR. LEE'S TABLE 





<ol 




43 


Length 


Adhesions 


Error of 


Complica- 


Character of the 




No. 


£ S 


Operator. 


be 


of 


or 


Diagnosis 


tion with 


tumor, 


Cause of death. 




P) c. 




< 


incision. 


not. 


or not. 


other dis- 


cystic or not. 






O 












eases. 






64 




Dr. C. Clay 




Large 












65 




Do 




Large 












66 


1842 


Mr. Walne 


58 


Long 


None 






Cysts, with 
solid tumor. 




67 


1843 


Do 


57 


Long 


None 






Cysts. 




68 


1843 


Do 


20 


Long 


None 






Cysts. 




69 


1843 


Do 


54 


Long 


Ext.Adhes. 


Not rem. 




Cyst. 




70 


1844 


Do 


45 


Long 


None 




Uterine 


Cysts solid and Tumor of uterus 
J a A j resting against 
nuiu. | incision. 














disease 


/71 




Mr. W., 

(B-k-s-w) 




Long 


None 




Exhaustion 
before ope- 
ration. 




Peritonitis. Ex- 
haustion after 
3d day. Great 
tympanitis. 


72 




Chrismann 




Large 


None 










73 




Mr. Crisp 




Unknown 








Cyst. 




g74 


1843 


Mr. Morris, 
(Rochdale) 




Large 












hi 5 


1843 


Mr. Southam 


37 


Long 


None 






Cystic sarcoma. 




76 


1845 


Do 


38 


Large, 
6 or 7 in. 


None 






Cystic. 




i77 


1843 


Dr.F. Bird 


35 


Small,4iin. 


None 






Cysts. 




78 


1843 


Do 


21 


Small, 5 in. 


None 






Cysts and solid 
matter. 




79 


1844 


Do 


35 


Large, 8 in. 


Strong 






Cysts and col- 
loid disease. 




80 


1844 


Do 


21 


Small, 3 in. 


None 






Cysts. 




81 




Do 


21 


Small, 5 in. 


Adhesions 
strong 






Multilocular 
thick cyst. 




82 


1846 


Do 


52 


Short, 5 in. 


Strong 
pelvic 






Cystic very thicfc, 
"and filled with. 


















cholesterine. 














adhesions 










83 


1S43 


Dr. T. L. Atlee 


29 


Long 


Adhesions 






Cysts and hydatids. 




84 


1844 


Do 


42 


Long 


Adhesions 




Disease of 
uterus. 


Fibrous tumor 
of uterus. 


Hemorrhage 


85 


1S43 


Mr. Heath 


40 


Long 






Disease of 
uterus. 


Fibrous tumor 
of uterus. 


Haemorrhage 


*86 


1S43 


Mr. Lane 


28 


Short, 5 in. 








Cyst. 




87 


1843 


Do 


45 


Large, 8 in. 


Adhesions 






Cysts and solid. 


88 


1844 


Do 


3S 


Large, 7 in. 


Adhesions 






Multilocular 
cyst. 




89 




Do 




Large, 7 in. 


Adhesions 










90 




Do 




Small 


None 






Multilocular 
cyst. 




91 




Do 




Large 


Extension 






Multilocular 
cyst. 


Peritonitis 


92 


1843 


Mr. Key 


19 


Long 


None 






Multilocular 
cyst. 


Peritonitis 


93 


1843 


Mr. Greenhow 


29 


Long 


Adhesions 




Disease of 
stomach. 


Cyst, with a dense 
vase ulo- cellular 
tumor. 


Peritonitis 


94 


1843 


Mr. B. Cooper 


32 


Long 


Adhesions 




Malignant dis- 
ease of ute- 


Solid and cysts. 


Peritonitis 


95 


1844 


Dr.W.L. Atlee 


61 


Long 


None 




rus. 


Bilocular cyst. 


Insidious pe- 
ritonitis. 


96 


1844 


Do 


24 


Long 


None 




Uterus dis- 
eased. 


Fibrous tumor 
of uterus. 




97 




Ehrhartstein 


36 


Large 


None 






Solid and cysts. 





DR. LEE'S TABLES. 



321 



Time of 








death 


Result. 


Remarks. 


References. 


after 








operation. 










Recovered. 




The particulars of both these unpub- 




Recovered. 




lished cases were kindly given me 
by Dr. Clay. 




Recovered. 




Churchill's Essay, and Med. Gaz., 
Aug. 11, 1843, p. 699. 




Recovered. 


Narrow escape, followed by phlegmasia dolens. 






Recovered. 


Tumor 28 lbs. 


Ibid. Oct. 13, 1843, p. 47. ' 




Recovered. 




Ibid. Feb. 23, 1844, p. 686. 




Died. 


Fibrous tumor of uterus, resting against incision, 
was supposed to have produced inflammation, 
and death. 


Ibid. March 10, 1844, p. 783. 


6 days 


Died. 




Unpublished. 




Recovered. 


Tumor 8 lbs. Recovered in 6 weeks. After- 


Psaif's Journ. vol. xii. part i. 






wards pregnant. 


« 




Recovered. 




Lancet, Dec. 




Recovered. 




Churchill's Essay, from the Manches- 
ter Courier. See note. 




Recovered. 


Ligature drawn into the abdomen, but incision 
entirely healed. 


Med. Gaz. 1843. 




Recovered. 


The ligature came away on the 49th day. Left 


Prov. Med. & Surg. Journ. Sept. 10, 






ovaries tapped and extracted. 


1845. Med. Gaz. May 26, 1846. 




Recovered. 


Sac punctured, drawn out, the pedicle tied, sac 


Lond. Med. Gaz. March 22, 1844, p. 






removed. 


832. 




Recovered. 


Incision 5 inches, cyst emptied, withdrawn, and 
excised, no pedicle. 


Ibid. Dec. 29, 1843, p. 409. 




Recovered. 


Many adhesions, sac emptied of a firm gelati- 
nous matter, excised tumor 35 lbs. 


Ibid. Aug. 18, 1843, p. 732. 




Recovered. 


Followed by slight peritonitis. 


Ibid. Dec. 8, 1843. 




Recovered. 


Case not published, but given to me by Dr. F. 

Bird. 
Cyst tapped and extracted : there was no pedi- 


Not published. 




Recovered. 


Not published, but particulars given 






cle ; and a small section of the uterus was re- 


me by Dr. F. Bird. 






moved with it. 






Recovered. 


Both ovaries removed. 


Am. Med. Journ. Jan. 1846, p. 44. 


5th day 


Died. 


4 uterine tubercles, with thick vascular pedicles, 


Ibid. vol. xxxv. 1845, p. 335, Atlee's 






extensive adhesion, hemorrhage from slipping 


table. 






ofligature. 




17 hours 


Died. 


The uterus and all were removed. 


Med. Gaz. Dec. 8, 1843, p. 309. 




Recovered. 


Phlegmasia dolens followed the operation. 


Ibid. 1844-45, p. 84. 




Recovered. 


Two cysts emptied before removal. 






Recovered. 


Cysts emptied before removal, the cyst sessile, 


Med. Gaz. 1844-5, p. 84. JeafFreson's 






and firmly attached to the fundus and neck of 


table. 






the uterus. 






Recovered. 




Philips' table. 




Recovered. 




Not published. 




Died. 


Adhesion to liver, suprazenal capsule. Ascend- 


Unpublished. The particulars of both 






ing vena cava. Kidney and intestines poste- 


these operations were kindly given 






riorly. No adhesions anteriorly. 


me by Mr. Lane. 


9th day 


Died. 


Large vessels on tumor. 


Guy's Hospital Reports, Oct. lS43,p. 
473. 
Med.-Chir. Trans, vol. xxvii. p. 88. 


7th day 


Died. 


For 4 years previously had uterine hemor- 






rhage. 






Died. 


A portion of the omentum was included in the 
ligature. 


Ibid. vol. xxvii. p. 76. 


6th day 


Died. 


Colon involved in a broad pedicle: both ovaries 


American Med. Journal, July 1S44, 






diseased. 


p. 43. 




Recovered. 


Thick fleshy pedicle, followed by violent peri- 
tonitis : intestines troublesome. 


Ibid. April 1S45, p. 309. 




Recovered. 


Tumor tapped before extracted. 


Med.-Chir. Trans, vol. xxvii. p. 473. 
Philips's table. 



21 



322 



DR. LEE'S TABLES. 



No. 



98 

99 

100 

101 

2102 

103 
104 
105 
106 
107 
108 
109 



'110 
111 



112 
113 

114 
ill5 



0116 



117 
pll8 



° 2 
S 3 

at 

o 



1844 

1844 



1845 
1845 



1846 
1846 

1846 
1846 



1846 



1846 
1846 



Operator. 



Dr. Hopser 
Do 
Macdonald 
Groth 

Morgan 

A. B. 

CD. 

E. F. 

G. H. 

Case in Gooch 

Dr. Bowles 

Prof. Webster 



W. B. Page 
John Dicken 



Dr. Handyside 
Mr. Solly 



Dr. Protheroe 

Smith 
Mr. Arrowsmith 
(Shrewsbury) 



H. E. Burd 

(Shrewsbury) 



Mr. W. 
Caesar Hawkins 






Length 

of 

Incision. 



Large 
Large 
Large 
Large 

Small, Hin. 

Long 
Small 
Large 
Large 
6 inch. 
Long 
Long 



33 Small, 4 in 
18;Large,14in 



26 



18 



Large 
Short, 4 in 

Large 
Short 



Long 



Long 
Small, 3 in. 



Adhesions 

or 

not. 



Adhesions 

Adhesions 

None 



Adhesions 
Adhesions 
Adhesions 



Adhesions 
Adhesions 



None 

Extensive, but 
cavity broken 
down. 



None 



None 

Very ex- 
tensive. 



None 



None 



Error of 

Diagnosis 

or not, 



Not re- 
moved. 
Not rem 
No tumor 



No tumor 



Not re- 
moved. 



Not re- 
moved. 



Complica- 
tion with 
other dis- 
eases. 



Character of the 

tumor, 

cystic or not. 



Cause of death 



Solid tumor. 
Solid tumor. 

Cysts. 



Chronic 
peritonitis 



Solid tumor. 

Cyst. 



Cysts. 
Multilocular 
cyst. 

Cyst. 

Unilocular cyst 
of right ovary. 

Multilocular. 

Multilocular. 



Multilocular. 



Unilocular. 



Haemorrhage 



Ileus and phlebi 

tis of the lower 

limb. 
Hemorrhage from 

slipping of the 

ligature. 

Shock of ope- 
ration. 



a Case 1 . From the American Journal of Med. Science, vol. xxxv. 1S45. p. 262. Still continues to enjoy good health 
_ Case 2. Dr. M'Dowall states, that he thought his patient well of her disease : " but she informed me a short time 
since that it had been growing for the last 12 or 18 months, and says it is now about the size it was when I opened her 
six years ago. 

Case 4. "She recovered happily, but I am told her health is not good; the account I had ofherwas awkwardly given; 
from what T could learn, her complaint is hysterical." 

b I have been unable to obtain the Monthly Journal of Foreign Medicine, vol. iii. p. 440, Phil. 1829, but presume these 
five operations to be correct, having extracted them from Dr. Atlee's Table. Amer. Jour. Med. Science, April, 1845,p. ^30 

c The anonymous of Dr. W. L. Atlee's Table. 

d I feel greatly indebted to the politeness of Dr. Clay in giving me a corrected list of the operations he has already 
performed. I am also authorized to mention, that Dr. Clay says in a note to me: "I took a survey of the state of all my 
successful cases for my particular friend. Prof. Simpson of Edinburgh, and found them all in the enjoyment of better 
health (since the operation) than for many years previously." 

e Cases 52 and 6i. These cases, T have authority for stating, were not operated on "as ovarian." "This was the ap- 
plication of the same operation to disease of the uterus, which, though not successful, ought not to be included in the 
statistics of Ovarian operations." Dr. Clay's note. 

/ Case 7L. This case has not been published, but was related to me by the nurse who was present at the operation. 
Also at the Office for the Registerof Deaths. 

g Case 73 has been disputed, on account of the authority it was originally taken from, viz., the Manchester Courier: 
but I have authority to state, that Mr. Morris did operate on. a patient, and was successful. 

h Case 75. "On referring to the report of my former patient," says Mr. Southam, " it will be found that the tympanitis, 
and obstinate vomiting which supervened on the operation, caused the ends of the ligatures to be drawn within the ab- 



DR. LEE'S TABLES. 



323 



Time of 

death 

after 

operation. 



Result. 



Remarks. 



References. 



30 hours 
16 hours 



Died. 

Recovered, 

Recovered, 

Death. 

Death. 

Died. 
Recovered, 
Recovered 

Death. 
Recovered 
Recovered 
Recovered 



Recovered 
Recovered 



70 days 
1 1 hours 



4 hours 



Died. 



Died. 



Died. 



Recovered 



Recovered 



Recovered 
Recovered 



Ascites. 

Malignant tumor. 
Tumor 22 lbs. 

A portion of fluid removed before extraction 
2 lbs. of blood found in the pelvis. 



Not removed on account of adhesion. The 
patient rapidly recovered from the operation, 
after the peritoneal cavity had been exposed 
for two hours ; but the disease progressed, 
and she died from it in about 2 months. 

Tapped and extracted. 

The ligature came away in 3 weeks. Each ar- 
tery was tied separately. The whole pedicle 
was not included. Left ovary healthy. 

Both ovaries diseased and extracted. 

A portion of the pedicle, containing the Fall, 
tube, slipped from the ligature, and gave rise 
to hemorrhage ; left ovary diseased. 

Tumor weighed 20 lbs.; fluid 10 lbs. 

An exploratory incision was made of a few 
inches in extent, but the adhesions were 
found to be so strong and extensive that the 
operation was considered unjustifiable. 

The patient recovered without any untoward 
symptom. 

The weight of the tumor, with its fluid and 
solid portions, 50 lbs. The patient was preg- 
nant of about 3 or 4 months' standing, and 
aborted forty hours after the operation. 

Ligatures came away from the 22d to the 25th 
day: the wound entirely healed on the 29th 
day. 



Med.-Chir. Trans, vol. xxvii. p. 473 

Ibid. [Philips' table 

Ibid. 

Ibid. PsafF's Journal. 

Philips' table ; and from Dr. F. Bird. 
who saw the operation. 
Philips' table. 
Ibid. 
Ibid. 
Ibid. A case unpublished. 

Western Lancet, Oct. 1846. 

Not reported. American Journal of 

Medical Science. Atlee's table 

vol. lv. p. 335, 1845. 



Lancet, April 5, 1845, p. 397. 
Provincial Med. & Surgical Journal 
for Oct. 7, 1845. 

Edinb. Med. & Surg. Journ. 1846. 

Chemical Lecture. Lond.Med. Gaz. 
July 10, 1846. 

Unpublished, but at which I was 

present. 
Unpublished; and the particulars 

given to me by T. Y. Arrowsmith, 

Shrewsbury. 



Unpublished; and the particulars 
given to me by H. E. Burd, Shrews- 
bury. 

Unpublished. 

The particularskindlygiven to me by 
Mr. Caesar Hawkins of St. George's 
Hospital. Med. Gaz. Oct. 30, 1846. 



dominal cavity; the wound had perfectly healed, and the patient was restored to health, whilst they were still in the 
abdomen. After several weeks had elapsed, a small abscess appeared at the lower part of the cicatrix, an opening 
into which gave exit to a quantity of healthy pus and the ligatures. A free discharge was promoted by poultices for 
a few days, and at the end of the week the wound closed. No constitutional disturbance occurred, and there lias not 
been the slightest interruption to the most perfect state of health since the termination of the report. The catamenia 
appeared with the greatest regularity, and in the same quantity as previously to the commencement of the disease. 
There is a tendency to corpulency, which is in a great measure checked by her active habits." Provincial Med. & 
Surg. Journ.. Sept. 10, 1845. * All Dr. F. Bird's cases are doing well. 

k All Mr. Lane's patients are doing well; he gave me the account of the two unpublished cases. 

I Case 102. This case was operated\ipon by Mr. Morgan of Guy's Hospital, and is the same as the one reported as by 
Dr. Ashwell, and "Guy's Hospital," in Dr. W. L. Atlee's Table. Am. Jour, of Med. Science, vol, xxxv LS45, p. 333. 

m "I may take this opportunity of mentioning, that the woman from whom I removed an ovarian tumor in August. 
1844, was, when [ last heard of her, some months since, in good health, and following her usual occupation, that of 
an itinerant dealer in pens and paper, in the neighborhood of Edinburgh."' Mr. \V. B. Page has again performed 
the abdominal section; the particulars of the case are given in the Lanctl for Dee. 18, L846, whence the above remarks 
are taken. 

n Case 115. I here beg publicly to thank T. Y. Arrowsmith, Esq., and H. E. Burd, Esq., loth of Shrewsbury, for 
their great politeness in giving me the particulars of their cases, 1 1">. 1 1 6, 

o Case 11(5. Mr. Burd states in a note, that "on this, the seventeenth day from the operation, the patient is doing well. 
and gives fair hopes of recovery." 

p These last four cases occurred after this work was in the press, and therefore are not included in the statistical 
results. 



324 THE FALLOPIAN TUBES. 



LETTER XXVI. 

Gentlemen : — The Fallopian tubes, like the ovaries and other 
generative tissues, are liable to disease ; but it unfortunately hap- 
pens that the Fallopian tubes being hidden within the bony cavity 
of the pelvis, and not approachable either by the vaginal touch 
or the hypogastric palpation, may be the seats of disease, pro- 
ceeding to the most inconvenient or even dangerous extent, with- 
out our being enabled to detect its existence by any process 
having the clearness of demonstration. I presume, indeed, that 
for the most part, Fallopian disorders will scarcely be clearly 
made out until a necrological examination may serve to reveal 
them. This opinion, I think, is well founded, except, perhaps, 
as to some samples of tubal pregnancy, of which the signs, too 
late discovered, are sufficiently clear to admit of our pronounc- 
ing boldly upon the case. 

Affections of the Fallopian tubes may serve to condemn a female 
to incurable barrenness. Thus, if a female, in early life or later, 
should experience an attack of acute peritonitis, marked with the 
characters of adhesive inflammation, the Fallopian tubes, one or 
both of them, might become attached by adhesive bands to the 
broad ligament, or to the bladder, so as effectually to prevent a 
tube ever afterwards from serving as a conductor of the ovulum 
to the womb. In such an instance, it would be impossible for 
fecundation to take place, and equally impossible to make the 
diagnosis of the accident during the person's lifetime. 

An adhesion of a Fallopian tube to the broad ligament, leaving 
the other one free to fulfil its office of excretory duct to the ova- 
rium, would not, however, at all interfere with the reproductive 
power of the woman, since one ovary might produce germs for 
the fecundative conflict. Neither would such an adhesion ex- 
pose her to any danger of suffering from violent traction and 
disruption of the adhesion in case she should become pregnant, 
when the womb must rise upwards to the height of the scrobi- 
culus cordis ; because, the broad ligament itself equally yields to 
the distending force of the growing womb, and thus carries the 



DISEASES OF THE FALLOPIAN TUBE. 325 

adherent tube upwards along with itself. No great inconvenience, 
therefore, is to be apprehended from an adhesion of one tube. 
When both are adherent, so as to prevent the fimbriae from reach- 
ing the ovary, barrenness is inevitable. 

A Fallopian tube may become the seat of inflammation at its 
fimbria resulting in the closure of that extremity of the organ, 
while the uterine orifice of it also becomes closed. In this situa- 
tion it sometimes is found to be filled and greatly distended with 
water. A beautiful drawing representing this condition of the 
Fallopian tube is given by Dr. Hooper, at p. 61 of his Morbid 
Anat. of the Uterus, &c. 

M. Duges supposes that pain and inflammation in the region 
of the Fallopian tube, unaccompanied with swelling or hardness 
there, may be held as signs of inflamed Fallopian tube ; but I do 
not discern how such signs can be taken as evidence of that par- 
ticular malady, since they may be as well marks of disease 
attacking the round or broad ligaments, and I should place very 
little reliance on the diagnostic skill of any one for the particular 
diagnosis in question. All such maladies are and must, during 
their course, remain obscure and unknown, except as far as they 
introduce constitutional disturbance. 

The Fallopian tube has been found full of blood, probably 
menstrual blood. 

I am not aware that any one has perished from the escape of a 
quantity of menstrual fluid from the uterus, in atresia of the vagina 
or womb ; and yet it seems wonderful that where the uterus is ex- 
panded to the cubic content of twenty or thirty ounces of men- 
strual excretion, the uterine orifice of the tube should never suffer 
it to flow off into the peritoneal sac. The surprise is increased 
upon remembering that the tube is so expansible as we see it in 
some morbid specimens. 

For example. I attended a lady in her accouchement in June, 
1841. She had a favorable labor, and all the usual circumstances 

of a lying-in woman attended her for a period of hours, 

when she complained of heavy and distressing pain in the region 
of the right Fallopian tube. The pain, and the complaint of it 
were great. Of a sudden the pain began to spread over the lower 
belly, and the constitution evinced its participation. The pulse 
became alarmingly excited and accelerated, and she was soon 
seen to be far gone in a puerperal peritonitis. As she had com- 



326 DISEASE OF THE FALLOPIAN TUBE. 

plained of pain in the right side for some time before the ac- 
couchement, I feared that some local malady, suddenly aggravated, 
was at the foundation of the danger. She died; and upon in- 
specting the abdominal cavity, much pus and sero-pus were 
observed. But what most particularly struck me, was the state 
of the Fallopian tube, which was much larger than a stout man's 
thumb ; and its cavity, which would freely admit of the introduc- 
tion of a finger into the tube, had been filled with pus. I have 
little doubt, that acute inflammation of the tube, sealing the ovaric 
extremity of it, and afterwards filling and greatly distending its 
calibre with pus, discharged at length into the belly, is the true 
rationale of this fatal attack. 

As the Fallopian tube conveys the ovulum from the ovarium to 
the womb, it is occasionally liable to destruction from an arrest 
of the fecundated ovulum in some portion of the tractus. An 
ovulum, when fecundated, whether it be arrested in the tube or 
whether it be arrested in the uterus, makes its mesenteric attach- 
ment to whatever vital surface it is confined. No doubt is enter- 
tained as to tubal gestation. No doubt, therefore, can be had, 
that, in all such instances, the ovulum -was fecundated before it 
had passed down the whole length of the tube. 

When such a tubal conception hath taken place, the woman 
will probably deem herself pregnant, since the rational signs of 
conception, such as nausea, deeper tinted aureoles, and even 
failure to menstruate may attend the misfortune. 

No suspicion of the dreadful fate that impends the victim is 
aroused until the tube has attained the utmost degree possible of 
its expansibility. That degree will rarely allow her to go beyond 
the third month, before the tissue gives way, and the ovum burst- 
ing, pours its contents into the peritoneum, followed by torrents of 
blood effused from the ruptured arterioles and venules of the tube. 

If the patient complains, for some days before the accident, of 
pain in the region of the ovary, it is probable the pain will be 
attributed to some other than the true cause, and the first symp- 
tom of the rupture is characterized by an instant burst of distress 
and a rapidly developing inflammation, attended by the evidences 
of a simultaneous hemorrhagic exhaustion, and the speedy evi- 
dences of approaching death, seen in mortal pallor of the face, 
coldness and clamminess of the limbs, shortening respiration, 
and a vanishing pulse, repeated with inappreciable rapidity, 



FALLOPIAN PREGNANCY. 327 

Suppose you should be spoken to on the subject of a preg- 
nancy just commenced, for your counsel as to the conduct of the 
patient. If, after the lapse of six weeks or twelve weeks, you 
are hastily called to her, and find her in the condition above de- 
scribed, what other diagnosis have you to offer than that of a 
ruptured Fallopian tube? You see very clearly that such pheno- 
mena could by no means attend a sudden internal strangulation 
of a bowel ; and the antecedent health of the woman would not 
allow you to attribute her symptoms to a perforation of an intes- 
tine. You have no other diagnosis to offer, and, unhappily, the 
only consolation for you, under such circumstances, consists in 
your ability clearly to point out the nature of the causes, and pre- 
dict the verification of your decision after the death of the victim, 
which may be pronounced unavoidable. 

I was the distressed witness of a case of this kind, a few years 
since, in a fine young woman, who had been several years mar- 
ried without offspring, when she came at last to tell me, with un- 
feigned pleasure, that she was pregnant, and to take my advice 
as to her hygienic management. When her pregnancy had pro- 
ceeded a little beyond the second month, she arose from her bed 
in good health and spirits. She took a broom and began to sweep 
some part of her apartment, when, in an instant, she felt violent 
pain in the region of the ovary, became suddenly of a mortal 
paleness and coldness, and by the time I reached her apartment, 
was already sinking from the peritoneal hemorrhage. 

Here is another case that fell under my notice. 

Mrs. , aged thirty-two, a healthy woman, mother of four 

children, was in excellent health on Sunday, October 7th, 18 — . 
At six o'clock in the morning, she was gayly singing and playing 
with her young children at her country seat, about two miles from 
town. At seven o'clock, an hour later, her husband, who was 
sick in his chamber, heard her slowly ascending the stairs, and 
groaning heavily. Upon her entering his chamber he perceived 
her to be alarmingly ill. Her physician, Dr. , was imme- 
diately sent for. He found her with a pulse at 140, and com- 
plaining of violent pains extending from the top of the thorax, on 
the right side, quite down to the iliac region. He attended her 
all day, applied a blister to the right side of the belly, and gave 
her a cathartic, &c. She passed a dreadful night, but was easier 
the next morning at 8 o'clock, when the pulse was but 120 per 



328 FALLOPIAN PREGNANCY. 

minute. He left her for a short time, but found her symptoms 
aggravated upon his return. I was invited to see her with him, 
and met him at half past 2 o'clock, when she appeared to be 
dying. 

As she had vomited very much, and labored under excessive 
tympanitis, with violent pain in the whole belly, she got an ene- 
ma, which brought off a great deal of stercoraceous matter, but 
without any relief of pain. In half an hour she said "raise me 
up, my breath is leaving me," and she was slightly elevated on 
a pillow, when she immediately swooned, and died. 

Twenty hours after her death I inspected the abdominal cavity, 
which contained about thirty ounces of blood and bloody serum. 
The pelvis was filled with coagula, and much blood was lying 
among the intestinal convolutions. 

This blood escaped from a rupture in the left Fallopian tube, 
which contained a foetus of six or seven weeks. The ovary was 
somewhat enlarged. The womb contained a deciduous lining, 
and the canal of the cervix contained a claret-colored mucus or 
lymph. The womb was larger than a non-gravid womb, though 
not much larger. 

There is a lithographic print which very faithfully represents 
the appearance of the specimen, which you may see at page 107 
of my " Philadelphia Pract. of Mid.," 2d edition. 

What, alas ! can we do in these cases ? We could make an 
incision in the abdomen and clear away the coagula and the se- 
rum. But who is he bold enough to do so ? Who is he astute 
enough to discriminate betwixt all the possible causes of such 
phenomena, with so much clearness as to warrant him in the per- 
formance of a gastrotomy for Fallopian pregnancy? There is no 
such wise and bold surgeon; and, therefore, nothing remains for 
us but to extend all the relief within the narrow boundaries of 
our power, and calmly await and submit to the inevitable end. 
Such are painful scenes to the sensitive mind. They cast a co- 
lor of gloom over the pathway of the medical man, whose whole 
walk, indeed, is among those who are in pain, in weakness, in 
fear, or in the valley of the shadow of death. A physician may 
be calm, and even cheerful, but a merry doctor is a very singular 
phenomenon. 

The diseases of the Fallopian tube then, you perceive, are ob- 
scure, and very unmanageable where they become serious. 



OVARIAN PREGNANCY. 329 

Doubtless they are many times unsuspected, while they are the 
true causes of disorders treated under another name, and doubt- 
less their inflammations, spasms, neuralgias, and engorgements, 
may yield to constitutional and local remedies addressed to symp- 
toms supposed to depend on modifications of other tissues. 

I did not say anything as to ovarian pregnancy when I wrote 
to you my meagre letter on the ovaries, because I intended to 
say what I have now said on tubal pregnancy, and preferred to 
reserve my remarks on ovarian gestation for this connection. 

You know, for I have many times spoken with you of it, M. 
Pouchet's opinion that ovarian pregnancy cannot exist. M. 
Pouchet says, at p. 421, Theorie positive de V Ovulation spontanee, 
&c. : "I formally deny the existence of ovarian pregnancy. I 
admit, indeed, that the egg in the act of escaping from its cap- 
sule, may become fecundated by the sperm brought into contact 
by means of the fimbria, and that it may subsequently be devel- 
oped at the surface of the ovarium in consequence of adhesions 
contracted with that organ. But I have no idea of an ovarian preg- 
nancy as understood by writers, that is to say, a development of 
an ovulum still contained within its Graafian vesicle, and which 
by its development engenders a foetus enclosed within the very 
ovary itself." 

M. Pouchet, to whom we are indebted for the fruits of very 
great labor and research on this subject, can hardly, we would 
think, escape from the necessity of admitting a true ovarian preg- 
nancy, if he will consult Dr. Granville's account of the case pub- 
lished by him in the Lond. Phil, Trans., Part 1, 1820. In July, 
1845, I had the honor of an interview with M. Pouchet, at his 
house at Rouen, and a conversation took place, among other topics, 
upon this very one of the ovarian pregnancy. I stated my own 
conviction, that it is impossible to deny the existence of the ovaric 
gestation, and that the embryo might well be developed in the 
Graafian follicle, which I see M. Pouchet, in the above sentence 
published in 1847, does not admit — he adhering to the opinion 
that the development can occur only at the surface of the organ. 

It seems to me, gentlemen, that if you assert the mutual pre- 
sence and contact of the generative elements to be necessary to 
fecundation, you have no occasion to doubt the presence of the 
male element in the tube, in all cases of tubal pregnancy at least. 
and M. P. himself says, that it may be possible for fecundation 



330 OVARIAN PREGNANCY. 

to take place on the surface of the ovary, by the contact of the 
germ with sperm brought into the fimbria. 

My opinion at Rouen was, and is still, that the porule being 
formed for the escape of the ovule, which being retained within 
the capsule by the granular retinacula, it might be the subject of 
impregnation by sperm brought to it in the fimbria of the tube. 

Let us suppose the impregnation to have been effected — then 
some change of position covering the porule with a peritoneal 
superficies allowing of adhesion, the ovulum would be necessarily 
shut up in the crypt or cell, which having now become again a 
shut sac, development of the germ would go on absolutely in 
the interior of the ovulum, and Granville's fact, for facts are stub- 
born things, would be explained without at all shaking the con- 
clusions as to the oviponte. 

I cannot predict what may be the opinion you shall adopt on 
this point. I presume, however, there is not one among you to 
believe that the macula germinativa, which is on the inner wall of 
the germinal vesicle, which is buried among the vitellary corpus- 
cles of the egg, which itself is in the centre of the granular 
masses contained within the inner concentric of the Graafian fol- 
licle, hid below the tunica albuginea and indusium of the ovary, 
can be exposed to the sexual presence and contact by any pro- 
cess other than the spontaneous ovi-posit, which M. Pouchet 
describes. For my own part, I cannot imagine any other way in 
which the mutual influences of the generative elements can be 
brought into effectual activity. 

I do not, then, believe that in the ovaric pregnancies the fecun- 
dation has been effected, except through an opened Graafian 
cell, which being subsequently closed by adhesive inflammation 
at the edge of the porule, has allowed the pregnancy to go on in 
the ovary itself. 

The womb is so constituted as to admit of a development con- 
tinued throughout the nine allotted months of a gestation; its pro- 
vision of materials being ample for that purpose. No such provi- 
sion has been made for ovaric or tubal gestation: hence, within 
three months, probably, in most cases earlier, the fatal rupture 
of the containing walls will take place, and the patient lose her 
life. 

I have now treated in succession of the maladies and accidents 
of the external and internal genitalia. There are many points 



PUBERTY. 331 

which I have passed over in silence, because I have wished to 
avoid expressing an opinion upon subjects, on which I have had 
no practical or clinical knowledge. Others I have postponed to 
a future page, in order that I might not be compelled, on the one 
hand, to anticipate, nor, on the other, to separate subjects that 
have a sort of natural alliance. For example, ruptures or lacera- 
tions of the womb and vagina, it appeared to me, might better be 
arranged under the head of those diseases and accidents of preg- 
nancy of which it is my intention to treat. It will be my duty to 
say much upon the subject of the menstrua, an important item in 
the history of the female, and one whose modifications and dis- 
orders exert a mighty influence on her health and happiness. In 
order to approach this subject properly, I ought to make remarks 
on that important and interesting crisis, which is called puberty 
in the female, and, therefore, my next letter shall be on the sub- 
ject of puberty, or the puberic age. C. D. M. 



LETTER XXVII. 

Gentlemen: — I know not whether I shall in this letter succeed 
in setting forth with clearness, the views I have long entertained, 
or rather those which I have supposed myself to entertain on the 
subject of puberty in girls; I fear I shall not. A man may think 
he has clear views on points in physiology, or in general philoso- 
phy, and particularly in any metaphysical contemplation, while, 
in fact, his notions are not clear, but confused, indefinite, dim, 
and not readily explainable in words. In such a state of his 
mind, a man will be found unable to set forth a lucidus ordo of 
thoughts, for there is no such characteristic order in his opinions 
on the special topic ; and if a writer doth in this way fail, you have 
fair inference that he fails to be distinct and clear and coherent 
in his exposition because he is himself indistinct, confused, and 
incoherent in his appreciation of the subject in discussion. 

If you had happened to be eye witnesses of a certain historical 
event, you would, doubtless, expect to be able to relate all the 



332 PUBERTY. 

successive incidents thereof in a regular order, as they occurred ; 
but should you not be able to do so, it would be because you had 
observed badly, and kept no memorials or records worthy to be 
depended upon ; in fact you would not know or understand the 
events of which you had been eye witnesses, and which you sup- 
posed yourself to understand and remember perfectly well. We 
see constant examples of this uncertainty and imprecision of 
knowledge in testimony daily given to our courts and juries by 
witnesses called in the case. The truth is elicited only by cross- 
examination. 

Now, when in this letter I come to speak to you on the subject 
of puberty in girls, I consider myself as having been an eye wit- 
ness in the cases to be taken up, as to the events and circumstances 
that attend upon the puberic age ; for, the major part of along pro- 
fessional life has been past amidst such scenes and histories. 
During many years, I have frequently been charged with the con- 
duct of the health of young females entering upon, passing through, 
or already gone beyond the puberic age ; yet, notwithstanding I 
have witnessed so many cases requiring medical interposition, I 
confess that to write you a letter on the subject of puberty ap- 
pears to me a most difficult task. Certainly it is one I should 
prefer to avoid, both because of the doubts existing in my own 
mind as to the peculiar nature of the puberic affections, and of 
the jejune and little practical notions upon it that I find in the 
authorities, which I take to be a proof of the difficult nature of the 
subject. I must pray you, therefore, beforehand, to scan very 
closely the sentiments that I shall express in this letter, and if 
you find them to coincide with what is true, or probably true, to 
adopt and apply them ; whereas, if they should prove to be hypo- 
thetical and unfounded in truth, you ought to reject and condemn 
them. I desire only that they should be useful, not merely that 
they should be acceptable. 

The writing a letter upon puberty would not be a difficult 
undertaking, were one to confine himself to pointing out in 
the usual manner the period and general phenomena of the 
change from the girlish to the womanly estate. Nothing is easier 
than to say that at the age of fourteen or fifteen years the pelvis 
becomes expanded and consolidated, that the internal and ex- 
ternal genitalia and the lactiferous apparatus become completed, 
&c. &c. But such statements, that are to be found in all the books 



PUBERTY. 333 

on these matters, serve to throw but very little light on the 
abstruse subject of puberic disorders. 

I shall endeavor, then, to relate to you what are the opinions I 
entertain on the subject, and point out to you the indications of 
treatment for those young people, who approach dangerously and 
pass with risk through the great and important crisis of the pu- 
beric age. What is meant by the word puberty ? 

Stephens, in his Thesaurus, says: " Pubertas. Aetas in mari- 
bus qui est annus xiv., in foeminis xii. Pubertas plena xviii. 
annus est. Pubertas est emissio pubis, a qua anni pubertatis 
dicti sunt. Pubertas, generandi vis. 

Dr. Noah Webster, in his Dictionary, says, " Puberty. The 
age at which persons are capable of procreating and bearing 
children. This age is different in different climates ; but is with 
us considered to be at fourteen years in the males, and twelve in 
females." 

You see that Stephanus and Webster, I shall not take the 
trouble to examine any others, agree that puberty in females is 
the age of reproductive power just begun, and that that power is 
acquired at twelve years of age ; Stephanus says, plena at eighteen ; 
but you, even as young students of medicine, know that neither 
of these Dictionaries speaks truly, for the reproductive power is 
not attained at twelve years in the average of cases, nor does the 
average come at all near to twelve years — it is beyond fourteen 
years in this country. The first true and veritable eruption of 
the menses may be taken as the evidence of the girl having 
reached her puberic age, for that eruption is the evidence of germ 
evolution in the ovary, and even of the ovi-posit. This occurs be- 
tween fourteen and fifteen years of age. 

Instead of limiting the application of the word puberty to the 
state of the girl at the first mensual manifestation, I prefer to use 
it as referring to a long stage of preparation for the menstrual 
office, and to a stage, also, which extends far beyond the date of 
the first show, into the period when the function has become re- 
gularly established; so regularly and firmly, I mean, as to leave 
no doubt on the mind as to the permanent and normal acquisition 
of the power; a pubertas plena. The fact is, that many persons 
are to be met with, in whom it has never been perfectly esta- 
blished; persons in whom the power to menstruate exists, but 



334 PUBERTY. 

exists feebly, morbidly, interruptedly. All such persons have 
failed to pass through the crisis of puberty. 

A girl may have a sanguine discharge from her genitalia with- 
out having any pretension to be menstrual. I have observed such 
discharges in children at birth, in the month, and in little children 
under six years of age. When I have been consulted about these 
cases as extraordinary samples of precocious menstruation, I have 
been far from joining in such a preposterous notion. 

The young child is but the sketch, the ebauche, the mould in 
which are to be formed the organs of the woman. She employs 
some fourteen years of her life in consolidating and forming her 
body, in order to fit it for its high destiny as a reproducing agent: 
but the apparatus and the force necessary for the fulfilment of 
that destiny are not added, except as the last and crowning power 
of her constitution. Her weak and tender tissues, in the early 
years of life, could not possess the strength and solidity, nor could 
they furnish the materials, for the evolution and perfecting of the 
new being, which is for a series of following years to represent its 
parent, as one of the integers of the immortal genus, man. 

The earliest years of her life are occupied, then, in bringing 
her up to that point of perfect development of her alimentary, re- 
spiratory, innervative, and circulatory life, that may fit her for 
taking on the last great reproductive force. The time for taking 
up that force is the time of puberty. Puberty is the term of pre- 
paration to produce and mature ovarian ovules or germs, and 
discharge them from their capsules in the ovary. 

Having duly acquired this power and faculty, she has passed 
through the crisis of her puberty. She has transcended the pu- 
beric age, and has become a woman. She has become possessed 
of a faculty that she is destined to enjoy for nearly half of her life- 
time, and then, losing it again, she turns on the reverse of the 
path of life, and begins to descend to the bosom of the dust from 
whence she originally emerged. 

It might be true to say that the whole menstrual period of life, 
extending from fifteen to forty-five years of age, is a continual 
crisis for the female; yet, when once fully formed and estab- 
lished in the economy, it is become a nature and a habit, and 
ceases to have that character of crisis which more truly applies to 
the stage of preparation or inception of this great power, and its 
positive and firm establishment as a part of her life-offices. 



PUBERTY. 335 

A girl grows up from infancy, and from childhood, continu ally- 
developing, confirming, and consolidating her tissues and organs 
appropriate in their magnitude and their density to the particular 
stage of existence through which she is passing. In weight, 
stature, proportion, vigor, and intelligence, there is a continual 
conformable progress — not a non-conformable progress. The last 
faculty she acquires is the reproductive, the crown and glory of 
them all — it would be an unconformable progress in development, 
should its acquisition be either greatly anticipated or postponed in 
point of time. 

In growing up from the infantile to the womanly estate, she 
passes through many crises, great and important ones; but the 
greatest and most important of all is the puberic crisis. 

In the beginning is the crisis of establishing the new aliment- 
ary, and respiratory, and circulatory life, at birth. This being 
effected safely, and it often fails, she passes through another criti- 
cal stage at the eruption of the infant or milk teeth, which are 
brought forward by a series of vital paroxysms, if I make not use 
of too strong an expression. There is a stage of excitement, often 
diseased, at the eruption of the incisors; a second one at the bring- 
ing forward of the molars ; a third, attendant on the cutting of 
the cuspidate teeth, and another with the second molar eruption. 

Thousands, and tens of thousands, nay, millions of young 
children fail to escape the dangers of the age of their first denti- 
tion ; and the bills of mortality are swelled with the returns of 
death in children. The first, or milk set, having served their 
turn, the child incurs great hazard at the quasi paroxysm that. 
waits upon the second dentition. Many children now lose their 
appetite, their embonpoint, their gayety; they cease to play, and 
utter the glad voice among their shouting and laughing compa- 
nions. The pulse becomes compressible and frequent, and, upon 
the slightest motion, the heart beats with redoubled haste, and 
soon subsides again into a habitual languor of action. Fretfulness 
of temper, and frequent crying for any slight cause, or for no per- 
ceptible cause, mark what is very commonly, in families, known 
as the " cry-baby" age of children in their second dentition. 

Children suffer frequent distressing pains in the decaying and 
loosening out of their first teeth ; and a strange erethism of the 
parts about the mouth attends the tension of the gums coincident 
with the bringing forward of the permanent set. I have had 



336 PUBERTY. 

many patients under my care, whose health had been rendered 
wretched by these causes. Such patients have had convulsions, 
deranged bowels, palpitations, and hypertrophic throb of the 
heart, loss of appetite, cephalalgia, and other disorders, attributable 
to the difficulty experienced in forcing them through this especial 
crisis of life. 

Under circumstances of a crude, imperfect, saburral digestion, 
thus brought about, the growth is sometimes arrested for a time. 
Thousands of children attacked at this period by disease, are hur- 
ried to the grave. Measles, scarlatina, pertussis, &c, attack 
them, and they cannot resist the combined influences of a severe 
malady and a dental crisis, either of which encountered alone, 
w T ould probably be far less dangerous. In the progress thus far, 
also, many of the organs and parts of the child are found to be 
unequally developed. The heart, for example, which in its evo- 
lution of substance and power ought to move pari passu with the 
entire economy of the child, is not rarely found to get ahead of 
the other organs, and we observe by auscultation and other modes 
of inquiry, that the child of six or eight, has a heart suitable for 
a child of eight or ten years of age ; and that the non- conform- 
able power of this prime agent of the circulation exposes the pa- 
tient to danger of excessive determination of the blood to the 
head, to the lungs, to the liver, the spleen, &c. &c, afflicting it 
with epileptiform convulsion, pulmonary engorgements, hepatic 
obstructions, &c, according as the excessive momentum of the 
circulation happens to be determined. 

Nothing is more common than to observe the excessive and 
non- conformable growth of the head in young persons, by which 
they are exposed to great risks, but which is corrected, at a later 
date, by the rest of the system recovering its due proportion to 
the encephalon. If the child, even after difficulties encountered, 
gets well and safely through this period, it is safe for a term of 
years. 

In like manner, the girl approaches the greatest of all her criti- 
cal stages of existence. She has concluded all the preparatory 
stages, and if they have all been perfect and complete, she turns 
over from the childish or girlish to the womanly condition, with- 
out stay, let or hindrance. She glides onward, and is found to 
be a woman, and that without the least inconvenience or disorder 
of health. 



PUBERTY. 337 

The epiphyses of the bones, and all the individual pieces of 
which they are constituted, have become solidified and compacted. 
The coxal bones and the several portions of the os sacrum have 
each acquired the due firmness and solidity. The pubes are 
covered with the marks of womanhood, the external genitalia ac- 
quire larger proportions. The transverse and antero-posterior 
diameters of the pelvis have suddenly and visibly increased; the 
mammary glands and the aureole and the nipple are augmented 
in size. A growth of fine downy hair is observed on the upper 
lip, near the angle of the mouth ; a more considerable deposit of 
fat lends roundness to the limbs and grace to the contours of the 
young maiden. A new and different lustre sparkles in her eyes, 
which more promptly veil their brightness by downcast glances, 
or the continual dreamy and thoughtful drooping of the lids above 
them. Heightened colour in the cheek and lips, show the greater 
intenseness of the glow with which the fires of life are burning 
within. It seems as if the forces which had been employed to 
perfect the beautiful machine, by arranging and completing all 
its organisms, were now occupied with a sort of paroxysmal in- 
tensity in adorning it with all its graces and attractions, and 
setting upon it the seal of perfection. She is perfect ; in a few 
months she is habitually, naturally perfect — the crisis is over — 
inveni portum, spes et for tuna valete. 

Let us suppose, on the other hand, that all these acts of prepa- 
ration have been duly effected, yet the girl is not ready. Why is 
she not ready? She is seemingly ready for the great change; 
what lets its accomplishment? She marches up to the critical 
age and it flees before her. In vain the progress of weeks and of 
months urges her towards the goal of change ; but she changes 
not. Insensibly and by the slowest degrees the conformable re- 
lations of her organs are found to be dissolved. Her nutrition 
gives place to marcor and atrophy; her brilliant hues are replaced 
by sallow tints. The bright laughing eye is grown dim and 
sunken, her heart beats hurriedly, especially upon exercise. Her 
appetite fails, or some craving pica or malacia takes place of the 
normal desire for food; debility, exhaustion, mucous diseases, 
diarrhoea, or constipation, make daily inroads upon her already 
feeble life-domain, and, while everybody knows that she would 
be well if she could become a menstrual creature, few deem that 
to make her so it is only required to cure her of a disease of the 
22 



338 PUBERTY. 

endcngium, a disease whose existence is incompatible with the 
exercise of that great function. 

There is no reason to hope, under these circumstances, that the 
great transformation will be effected. Such nutrition, circulation, 
respiration, and innervation as hers, will not admit of it. It is far 
more probable that one system of functions after another being 
perverted, prostrated, and overthrown, she will become more and 
more diseased, feeble, and exanimate, until some local inflamma- 
tion finds her an easy and rapid conquest. You have no reason to 
expect to cure her of her emansio-mensium, until you cure her of 
her puberic malady. What is that malady ? — how will you pre- 
scribe for it ? — what is the indication ? — is it that everlasting calo- 
mel f — is it snake-root, senna, rhubarb, quinine ? — what is it ? — 
what ails the patient ? She is impuberic, though advanced far in 
the puberic age. 

Look at her — measure and weigh her— compare her with her 
former self. Don't you see what enormous efforts her constitution 
has made to transform her as it has done, from the condition of a 
child to that of a woman? Her great haunches are no more like 
those of the boyish pelvis she had ten months ago than her bust 
is like that of a boy. Her wide womanly pelvis, and the vast 
glutsei, the expansive levatores, the iliacse and psose, have been 
almost created as by a coup de theatre ; and all this at the ex- 
pense of effort by the iliac arteries and their branches, and accom- 
panying nerves. The same apparatus has been laboring with a 
surplus of activity to develop the uterus, the tubes, the vagina, and 
the external genitals, and all these parts are, perhaps, perfectly 
formed; but the sexual concrete, the vitelliferous tissue, the 
stroma of the ovary is incomplete. No yelk matter can it pro- 
duce ; there is no germinal spot yet, no germinal vesicle, no 
vitellus, no Graafian follicle, and, of course, no menstrua. 

She has lost her health ; she has fallen sick. She is useless in 
her present state and prospects as a reproductive agent ; and the 
reproductive vitellary element is withheld from her. Cure her 
health, re-establish the conformable relations of her organisms. 
Let her innervations become equable and universal for her micro- 
cosm, and she will give you the proof of her restored health in the 
assumption of her catamenial power. 

Open your books of therapeutics and materia medica. You 
find in them a great catalogue of plants, and minerals, and ani- 



PUBERTY. 339 

mal substances, under the head of menagoga, or emmenagogues. 
Does the young lady want an emmenagogue ? — and what ein- 
menagogue ? Is it tansy, is it hellebore, is it madder, that shall 
cure the puberic disease under which she labors? I ask you 
again to perpend the question — what ails her ? Let us try if we 
can learn what really ails the patient. 

If you will advert to the state of the creature in the earliest em- 
bryogenic period, you will remember that it passes first from the 
embryonal into the state of a foetus, and then into that of the child, 
the girl, and the woman; and that all these mutations are effect- 
ed by, and solely dependent on, the power of accretion, or nutri- 
tion of the parts. This accretion takes place at the expense of 
the blood, which is the pabulum, or the magazine, out of which all 
the new molecules are taken, and deposited under the indicating 
and controlling force communicated by the accompanying nerve. 
In fact, all life is but a continued scene of development ; and but 
for the waste and detritus of the organs, no limit could be as- 
signed to the extension of the body. It is this generic nature, or 
rather law, which compels all animal forms and parts to remain 
within certain boundaries, according to a pre-existing idea of 
such genus, or such species. Without such generic delimitations, 
it is plain that the whole zoological series, as well as all the vege- 
table forms would be lost in the progress of a few generations; 
whereas they have been kept until now, the exact copies of those 
archetypes which, in the Garden of Eden, were commanded to go 
forth and fill the earth, each after its own kind. It is the greatest 
miracle of all. 

Have we then any reason to be surprised, when we find that this 
long development of the foetus, the infant, the child, and the girl, 
sometimes exhausts the powers concerned in its effectuation? For 
example, the child grows too fast and falls sick, are you surprised at 
such an event? If the waste of the forces and materials of the blood 
is rapid and great under the double necessity of both maintaining 
the existing stage, and also of adding thereto, in order to rise to 
a higher stage of development, what wonder have we to perceive 
that the child that grows rapidly tall, also grows thin and weak, 
and pale, and sickly? or to hear its mother say it is sick for 
growing too fast? 

I assure you I think it must often happen that you shall be 
called to give your opinion on cases of the sort, in which you will 



340 PUBERTY. 

have occasion to observe that, when nature, after a violent effort 
and crisis of development power, shall have ceased to develop the 
child in stature, it will be found to augment in breadth ; and when 
that process is fairly instituted, it will cease to be lanky and thin ; 
for, in fact, in the growing up of children, you shall almost always 
find that they grow alternately tall and bulky. When the elon- 
gating crisis comes on, they grow thin towards the end of it, and 
are said by the vulgar, very truly, too, to " outgrow their strength." 
As soon as this weakness comes on, they cease to grow in longi- 
tude, and then commences the development or growth in latitude. 
So that the child becomes stout again, and so on it goes, growing 
by turns, first taller, then stouter, then taller again, and next 
stouter, until at last it shall have acquired its true generical limits 
and form. 

A child, I said, grows from the appropriation of materials taken 
out of the mass of the blood, which is the pabulum nutritionis. 
There is then a constant and wasteful call for supply. But 
whence the supply, gentlemen, and shall we not expect sometimes 
to find that the organs of supply become wearied and exhausted 
of functional power by the sheer excessive exercise thereof? 

And now, we come to the gist of the matter; what is it that 
makes the blood? what is the hsematosic tissue? That is the true 
question; and if we can settle that question, we shall succeed in 
setting forth in a clear and lucid order our doctrine as to the 
principal maladies of the puberic age in the female. 

An army of 100,000 men can be manoeuvred and marched 
according to the will of the general-in-chief, upon one. condition, 
and that is the condition that its rations shall be supplied ; for no 
courage, no discipline, no conduct on the part of the officers or 
men, can keep it afoot without the aid of the commissariat. The 
100,000 men would fall faster by famine, than by the bullet or the 
sword. The daily rations which keep the army up to the faculty of 
the highest activity and courage, are essential to supply the daily 
waste, consumption, or detritus of the life actions of the soldiers. 
The ration is converted to chyme, it next becomes chyle in the 
thoracic duct, and it is poured as chyle into the mass of the blood, 
when it is precipitated into the auricle of the heart. The churn- 
ing power of the chordae tendiniae mixes the new material with the 
sanguine mass, and it is hurried off into the system of arteries, 
capillaries, and veins, and after a few revolutions it is — what? — 



PUBERTY. 341 

blood. How has it become blood? If you answer, by the un- 
known force of the cell-life, I reply that a condition of the exercise 
of that cell-life force is this, namely, that it should be in contact 
with a living solid — and what solid? It must be in contact with 
the membrane commune of the vascular cyst, the membrana 
vasorum commune, the endangium, as Burdach calls it. Even in 
the very earliest manifestations of the ' presence of blood in the 
punctum saliensof the incubated egg, where the blood disc seems 
most like an independent self-creating physical ens, which makes 
its own vascular tractus, we cannot deny that the power to form 
itself is a transmitted power — transmitted from the living elements 
of the ovum itself, by which it is surrounded, and by which it has 
its being. The sanguine body could not become blood in the 
stomach, the duodenum, or jejunum, nor in the lacteal tube, nor 
the thoracic duct; but it can become blood while in contact with 
the interior lining of the vessels and nowhere else. Hence I infer 
that the membrane which lines the interior of the heart, the aorta, 
and all its branches, the capillary vessels, and all the veins, is a 
blood making surface, and that there is not and cannot be found 
any other blood making tissue in the economy. When this tissue, 
this membrana communis, is in perfect health, and the supply of 
chyle passed into it is perfect, we have perfect blood ; when the 
tissue becomes diseased, w T e have diseased blood, or at least it 
acquires a dyscrasy that prevents it from exercising its due influ- 
ence on the organs and tissues. 

So little is as yet known concerning the true nature and powers 
of the common membrane, that I dare not trust myself to speak 
of it without much hesitation and doubt of my correctness as to 
its diseases. But at least we do know that the membrane is 
liable to simple inflammation, to diphtheritis, to inflammatory exu- 
dation, to pyogenic inflammation, to adhesive and to destructive 
inflammation, and ossific degeneration, and that is enough to show 
us that it is also liable to debility, and to imperfect and unequal 
exercise of its functional office. 

Where it becomes the seat of a pyogenic inflammation, it car- 
ries death in its function, for it produces innumerable pus corpus- 
cles, which, being washed away into the circulation, poison the 
whole mass of the blood, and curtail the existence by purulent 
infection of the blood. 

When, again, it is endowed with a preternatural activity and 



342 PUBERTY. 

force, it, the blood membrane, fills the vascular cyst to overflow- 
ing with a rich and excessive blood, so that the patient labors 
under all the symptoms of plethora; and when it has lost its tone, 
or has exhausted its force by excessive exertion of it, we have the 
appearances that appertain to the anaemic state. 

Allow me to lay before you some remarks made on this mem- 
brane by Dr. Burdach, for which I refer you to the French copy, 
vol. vi. p. 194, of his Physiology, whence I have taken the fol- 
lowing extract, and which relates to a point in this discussion of 
the greatest interest. 

" § 698. A vessel is the special delimitation of the vital fluid, 
which constitutes a liquid, apart and distinct from all the other 
humors ; that is to say, the blood. It traces out the career which 
that liquid is to run, and marks out the direction it is to follow ; 
it may be considered as the expression of the blood in space, for 
it was formed by its current, and makes but one with it. 

"Hence it follows that the most essential part of the vessel 
must be in direct contact with the blood, and be the internal 
layer of its walls. This internal membrane (membrana vasorum 
commune, endangium) extends uninterruptedly in the heart, the 
arteries, the capillary vessels, and the veins. It is an elementary 
tissue, of a special nature, and cannot be referred to any one class 
of the membranes. According to Meckel, it possesses greater 
analogy to the serous membranes than to any others; and it is so 
by its structure, its vital properties, its tendency to adhesion, to 
inflammation, and ossification. It appears to me that it ap- 
proaches in character nearest to the character of the epidermis, 
seeing that it separates the blood from the rest of the organism, 
as the epidermis separates the whole body from the external 
world, and as its essential properties much resemble those of the 
epidermis. In fact, it is a uniform, thin, transparent, whitish 
coagulum, without anything special in its structure ; and the mi- 
croscope reveals in it neither globules, nor fibres, nor interstices, 
nor pores. It is true that Geri pretends to have discovered longi- 
tudinal fibres in it after macerating and drying it; but such an 
appearance manifested by a body in a state of putrefaction, cannot 
be alleged as proof of the existence of organic fibres. The in- 
ternal vascular membrane has neither vessels nor nerves. Ribes 
states that he has seen vessels in it when inflamed ; but every- 
thing tends to the belief that they were the vessels of the fibrous 



A 



PUBERTY. 



343 



coat seen through its transparent tissue. It is fragile, as it readily 
breaks when a ligature is drawn round a vessel; but it heals 
readily, and is reproduced." 

I cannot see how M. Burdach can dispose of the difficulty that 
surrounds his view of the membrane — a tissue, possessed of vital 
properties, capable of the adhesive inflammation, of healing pro- 
cesses, of being reproduced, &c, while he asserts it to be anhis- 
tous or without organization, a mere coagulum. I leave it to you 
to decide for yourself as to the probable correctness of his view of 
the case *, but, I advise you to read on this head a work by Raci- 
borski, on the veins ; a work in which he examines very much at 
large the history of their nature, uses, and maladies. Raciborski, 
you will find, holds that the veins, in penetrating into the most inte- 
rior structure of organs, carry with them only the endangium, the 
membrana commune, which, if that idea be well founded, is equi- 
valent to asserting that this inner membrane is the essential organ 
or agent, and that the fibrous and elastic, and other materials of 
the structure of blood-vessels, are merely the protective invest- 
ments of the blood-making organ. As for me, I shall continue in 
the belief that I have long entertained, that it is not only an organ, 
and a living one, but that it is one of the most susceptible to 
morbific impressions, and one whose modifications of health or 
disease exert the most important and diversified influences on the 
state of the entire economy. 

This blood-membrane, this hemapoietic organ, is interested in all 
the blood diseases. I doubt not it is one of the prime seats of the 
pathological lesions in erysipelas and scarlatina. It suffers in all 
the protracted intermittent^, it becomes diseased in multitudes of 
pregnant women, in women during lactation, in men over-fatigued 
and exhausted with vigils, in the badly fed and badly clothed, in 
the intemperate, in the broken-hearted, and in all those who are 
long deprived of solar light in dungeons and mines. It is the sole 
pathological organ in many samples of frequent deliquium, in 
many cases of supposed dilatation of the heart, or the large arteries, 
in neuralgia, and other neuropathic maladies. It is constantly 
affected in children during dentition, and very often in girls ap- 
proaching or passing through the puberic crisis, and in such as 
do not regularly menstruate. Disease, or debility of this mem- 
brane, is, in most cases, the puberic malady in girls. 

It is the chief seat of the pathological deviations in all the cases 



344 PUBERTY. 

of what the French call pales couleurs, and which we term green- 
sickness, or chlorosis. Its continuance is continuance of the 
malady, its cure is the cure of the patient. 

You may remember the occasion on which I spoke at consider- 
able length to the Clinical class, in Nov., 1846, on the case of a 
pale young woman, who came into the Clinic on account of a goi- 
tre ; and I beg you to allow me here to make for you a memo- 
randum of what was said by me in the clinique on that occasion, 
and an explanation of the motives that led me to recommend a 
particular therapeutical course for her. I think I counted her 
pulse for you, and found the beats were 75 per minute ; her re- 
spiration was equable and natural as to its frequency and com- 
pleteness. Her face of a dead-white or blanc-mate hue. She 
was not emaciated; her catamenia were suspended. 

This was the state of the patient while sitting at ease on a chair. 
But I wished to learn what would be the effect of a slight muscu- 
lar exertion upon one, who, with perfectly sound lungs, ought to 
be able to make a considerable effort without adding considerably 
to the number of respirations or of the pulsations. For, in order 
that a muscle should contract, there must be sent into it a stream 
of nerve-power — call it excito-motor if you prefer. But that 
stream is developed in the brain or spinal cord, and the stream 
will not flow if the source be not supplied. In a sitting posture 
the supply was abundantly equal to the demand. But let us see 
whether she can obtain the supply under strong effort, with the 
heart and lungs acting at their present rate. I presume she can- 
not ; and my reason for so thinking is this : I find her pulse soft, 
compressible, large ; her skin pale, the rosy tinted mucous mem- 
branes of the mouth and throat whitish, bleached. Her lungs, on 
percussion and auscultation, perfectly healthy, and, in fact, while 
she sits here and has nothing to do, she is well enough. Because, 
with the present rate of her circulation and respiration, there is 
generated a sufficient amount of nerve-force to innervate all her 
muscles, and, indeed, all her organs. Were she lying down, the 
necessity for all muscular exertion being suspended, the supply 
of innervative power is superabundant, perhaps. How is this 
nerve-stream produced ? Is it not evolved by the action of the 
blood upon the matter of the brain ? I mean, in strictness, the 
action of oxygen on the matter of the brain. Can black blood, 



PUBERTY. 345 

venous blood, determine in the brain the evolution or extrication 
of the nerve-force, the nerve-stream? If you enrich the blood by 
good diet, if you highly oxygenate it by exercise in the air, if you 
increase the impetus of it by motion, by champaigne, by nitrous 
oxide gas, by the exciting passions of the mind, do you not in- 
crease the energy of the innervative force, by sending into the 
brain larger supplies of oxygen in its vehiculum the blood ? But 
in the present case, if I am correct in supposing this girl's blood 
to be thin, watery, aqueous, how can she upon any considerable 
necessity for extraordinary evolution of nerve-power — how can 
she get at that evolution, sending, as she now does, a dilute, aque- 
ous, anemical fluid, instead of the rich stream which circulates in 
your vascular system. 

If she must make the effort, she must supply the material, she 
must inject the oxygen into the brain; and how? By increas- 
ing the rapidity of the injection; how? By doubling or trebling 
the number of pulsations, and increasing their force. 

That immortal physiologist, Xavier Bichat, has set this matter in 
the clearest light for us. He has shown us that life in the mammal 
consists in a trinitarian power of the brain, the heart, and the 
lungs. When once endowed with the gift of life, we cannot put 
it off but at one of the angles of this triangle. 

The blood is oxygenated in the lungs, the heart injects it into 
the brain ; the brain touched by the oxygen is compelled to send 
forth the stream of innervative force to all the organs. If the 
lung dies, no more oxygen, no more nerve-stream, and the cessa- 
tion of all motion, which is the consequence, is death. Again, if 
the heart dies, no more oxygen reaches the brain, whence flows 
no more the nerve-stream to the lungs ; if the brain dies, no more 
motion, no oxygenation of blood in the lungs, and no motion of 
the heart to inject it to the brain. 

This is Bichat's view. But do you not, under this aspect, per- 
ceive that if the blood in the lungs is not healthful, the oxygenat- 
ing power will be incompetent to a certain extent, and the brain 
to a certain extent will fail to radiate its nerve-force to the organs, 
and so, as to all the consequences of such a dyscrasy of the 
blood? The pale girl near us has blood incompetent to be en- 
dowed perfectly with oxygen. But so much oxygen so much 
nerve-force, — so little oxygen so little nerve-force. 

In the healthy individual, fourteen or sixteen respirations per 



346 PUBERTY. 

minute suffice to oxygenate the blood perfectly ; in the unhealthy, 
there may be required twenty-eight or thirty-two respiratory acts 
per minute. It is not rare to see the respiration rise to sixty ; for 
without oxygen we die, and if fifteen breathings will not endow 
us with enough, we must breathe fifty, sixty, or 120 times per 
minute. Suppose the blood of this patient be represented by 
corpuscles fifty, albumen eighty, fibrine ten, then the water must 
be 860; but it ought to be 790. Do you think that blood, whose 
water stands at the figure 860, can carry so much oxygen to the 
brain as that whose figure is normal, at 790 ? And, if there be 
demand for considerable nerve-force, can it be yielded without 
increase of the pulsations, and the respirations to the reflex innerva- 
tions, or to the voluntary ones ? Do you not know that when the 
ordinary rate of the respiration becomes insufficient, the free will 
of the patient comes to add the force of its innervative power to 
the ordinary respiratory innervations ? and that an instinctive feel- 
ing of the necessity of air compels all the nerves connected with 
the act of breathing, to lend their aid in carrying on that functional 
act ? The medulla oblongata knows the system will die if it re- 
double not its power and influence. 

Let us try the experiment in this case. 

Accordingly she descended the stair-case to a lower floor, some 
twelve or fifteen feet, and then returning on the ascending stairs, 
came to take her seat again in your presence. Her pulse when 
she left the amphitheatre was at 75, and when she had come up the 
stairs, after an absence of two minutes, it was 150. The respira- 
tions at 18, became six and thirty. She was out of breath and 
the heart in a state truly deserving to be called palpitation. 

As I am desirous to be understood I am sure you will allow me 
to give a rationale of this change. 

The act of descending the stair w T as, probably, not accompa- 
nied w T ith any,, or, if any, with slight augmentation of the heart's 
frequency, because little muscular effort is required to descend, 
but the labor of lifting a body in opposition to gravitation is 
great — hie labor, hoc opus est — and the brain could not supply 
the nerve force when stimulated to do so by an anaemic blood in- 
jected at a moderate rate. The first step in ascension is therefore 
caused by a great effort of the free will, which is itself a FORCE, 
which determines the muscular innervation, but such an exer- 
tion of the Free will is consentaneous with augmented evolution 

i 



PUBERTY. 347 

of the excito-motory force determined to the heart. The mere 
intenseness of the effort to rise upon the first step is sufficient 
to determine an increased activity of the heart's motion, perhaps 
upon the principle of the physiological reactions. M. Dessaus- 
sure, in his ascent of Mont Blanc, found that at the height of 
ten or eleven thousand feet, none of his party could move more 
than a few feet without panting for breath, and being compelled to 
rest a few moments before renewing the attempts to ascend. Des- 
saussure and all his men were, though in good health a few hun- 
dred feet lower down the mountain, actually in the state as to 
respiratory power in which the anaemic girl is found at the level of 
the base. That is, the blood, though its crasis was not different on 
the mountain, could not convey to the brain the necessary quantity 
of oxygen; for with the barometer at 16 or 18 inches, so great is 
the rarity of the atmosphere that two or three ordinary aspirations of 
air could not impart so great a quantity of oxygen to the blood as 
one moderate one would endow it with at the sea-level. My pa- 
tient coming from the lower floor is compelled to breathe fast and 
redouble the systolic effects, and thus you see is set on foot a train 
of innervations of the locomotive muscles and of the heart's mus- 
cles commensurate with each other and commensurate with the 
wants of the occasion. Her state at this level is precisely like 
that of Dessaussure at 11,000 feet on Mont Blanc. 

By the time the young woman had regained her seat, the heart, 
the brain and the lungs were all in a fury of excitement, which 
soon subsided, as it always does, upon a cessation of the effort. 
Here, then, is a case in which the organs are imperfectly inner- 
vated, while the patient is in the act of taking exercise, from want 
of power to supply the brain with the normal quantity of oxygenated 
blood. The Dessaussure party presented the same phenomena, be- 
cause they were breathing a rarefied air. They were not diseased. 
The girl who manifests the same phenomena is diseased, she has 
too little oxygen, and the disease is debility of her endangium. 
I do not say, endangitis or phlebitis, but loss of tone of her blood- 
membrane. What is the indication? To restore the tone to her 
blood-membrane. If you can effect that — her cerebro-spinal axis 
will innervate all her organs healthfully — and she will be restored 
to health. 

I hope that you now understand my meaning* on this subject ; 
if you do understand me, it is because I have been enabled to 
explain a meaning that I myself understand; if you do not, I 



348 PUBERTY. 

have reason to fear that my own views are confused, unclear, in- 
determinate. Be that as it may, it is very certain that for some 
years past I have acted under these views, in my therapeutical pre- 
scriptions, for a great number of such cases; and that with a result 
so satisfactory, both to the patient and to myself, as to confirm 
me in the validity of the theory, or rationale under which I make 
choice of the remedies for the case. The prime indication being 
to cure the membrana vasorum interna, the endangium, the lining 
membrane of the blood-vessel — the blood-membrane. 

Let us now return to the consideration of the girl approaching 
to her pub eric age. 

She is turning from childhood into the new paths opened for her 
career. Her bones are to become solidified and expanded in their 
dimensions. The little hipless creature that you leave at home 
in January, as a child, is found when you return in November to 
have changed into a woman. The great broad haunch bones are 
already formed, and that in so short a time. The epiphyses are 
consolidated and indissolubly attached; the marks and traces of 
distinction in the pieces of the sacrum and the coxalia are all 
gone ; for the pelvis has been prepared during your absence to 
bear the weight and the strain of gestation and labor. The or- 
gans within have acquired the consistency, and the forms, and the 
capacities requisite to enable them to fulfil their great destiny and 
office. The stature has increased; the round and swelling limbs 
and the panting bosom have taken the place of that angular, and 
lean and awkward form that you left behind at your departure, 
and the whole creature, as to her physique and her morale, has 
been transmuted as by the stroke of a magician's wand. Does 
this cost nothing of life-force, life-effort, life-expenditure? Is not 
this great and sudden transformation, and loss, a stage of crisis 
and danger? Do you not perceive how needful it is to watch over 
and provide against the assaults of disease for the young girl : 
how her alimentation should be sustained by food, by the stimula- 
tion of insolation, of the open air, and the habituation of exercise, 
which is the absolute requisite of a perfect nervous induction. 

Suppose she be badly managed, and feeling badly, as often she 
does, she is indulged in a lounging life at home, with the imasri- 
nation on the rack of some passionate novel, and the digestion on 
the rack with cates and comfits, and every trashy aliment which 
her pica and malacia could prompt her to indulge in. But this 



PUBERTY. 349 

is not all: the young lady must be educated; she must learn 
astronomy, God wot! and algebra! she must speak French and 
Italian, at least ; it is imperative for her to have studied Latin, and 
geography, and rhetoric, and history, and natural history, and 
chemistry, and music of the piano, the harp and the guitar, and 
drawing, and embroidery, and dancing; but she cannot make pud- 
dings, nor milk the cows, nor confect an apple pie, nor sew, nor 
knit, nor spin, for her destiny is to rival the lilies of the valley. 
Behold them ! They toil not — neither do they spin — yet Solomon, 
in all his glory, is not arrayed like one of them. 

If a girl grow up like a pine knot she can't be hurt — you may 
do what you please — she is too tough and strong to be hurt by 
any educational process. But if she be truly a lily — lily white 
in her complexion — tender and nodding in her feebleness, like the 
flower on its stem — what hope have you to be able in the binary 
consumption of the thought-power and the development-power 
(both coming from the same encephalon) to carry her securely 
through the dangerous way in which her puberic age must walk? 

The girl has need to grow and become of full size and strength; 
but, if you send her to the boarding-school, and place her on the 
form, and put before her some dull and unintelligible gallimatias 
of grammar or mathematics, if you compel her to commit to me- 
mory mille versus stans uno in pede, how can she be expected to 
preserve her health and attain to those important developments? 

There is a passage in Raciborski's pretty work, " De la Puberte," 
&c, at page 44, which concurs with my own observation and ex- 
perience as to the influence of studies on the young girl. 

" I learn from a physician attached to one of the largest board- 
ing-schools in Paris, that the young ladies of the establishment 
are, for the most part, very tardy in making their change ; and 
that, when they have become catamenial, the menstrua are often 
very irregular." M. Raciborski adds, that "the physician could 
not well account for this peculiarity otherwise than by referring it 
to the nature of the diet, which, he thinks, is not sufficiently tonic. 
When these young ladies go home to their parents during the va- 
cations, and remain there a short time, the catamenia become 
very regular, but are deranged again soon after their return to 
school." 

I have attended at different times in some of the boarding- 
schools in Philadelphia, and I have never attributed the failure of 



350 PUBERTY. 

menstruation to any dietetic cause, because young ladies are well 
fed in those establishments. 

I assure you that it is very common for me to find young women 
who have grown up admirably, and who have turned through the 
straits of the puberic age in perfect safety and with complete 
success, to lose, in five or six weeks, the habit of menstruation 
upon being brought to town and set on the school form and com- 
pelled to undergo the fatiguing labor of the mental and educa- 
tional discipline and culture. Such a patient is too busy with the 
mind to attend to the body — the confinement, the study, the de- 
votion of innervative power to thinking in one train of thought, 
prevents the healthful innervation of the muscles, the skin, the 
alimentary apparatus — the biliary organs give way, the kidneys 
fail to cast out the nitrogenous surplusage of the economy, and 
the whole mass of the blood loses its fine and delicate crasis, and 
the endangium itself loses the power to keep up the constitution 
of the blood to its normal standard. 

In this condition of the whole system, where the organs have 
lost that harmony of life that is essential to the well performance 
of all the functions of life, there is no need for us to be surprised 
if certain of the offices of the economy, those exquisite deuto- 
biological offices, that rest like the topmost stone at the summit of 
the pyramid, should first fail to be manifested, or that they should 
be among the first to disappear where they have been once already 
made manifest. 

Indeed, almost the first perceptible change in the health of the 
female is the disappearance of the catamenial force. 

Do you not remember that while I was discussing this subject 
in the lecture-room, I said, that life in the general might be 
likened to a rocket? The flashing train rises out of the thick 
darkness of night, and glowing more and more the higher it rises 
towards the heavens — gives out, at length, when at its highest 
point of ascension, the last brilliant flash that fills the whole air 
with sparkling diamonds of light — the most perfect part of the 
exhibition — so in the female — the life has reached its high ascen- 
sion when at its culminating point, these sur-vital manifestations 
are beheld. 

But a woman in health will menstruate : therefore, when a woman 
does not suffer her regular monthly evacuation, it is because she is 
not in health. There is want of harmony somewhere in the play 



PUBERTY. 601 

of the organs. She in general does not become sick because she 
does not menstruate, but she ceases to menstruate because she 
has fallen sick. To make her become regular again it is only 
necessary to restore her health — for she is a menstruous creature, 
and will always fulfil her natural law if something does not pre- 
vent her, which, by acting upon her constitutional health inju- 
riously, prevents that constitutional force from developing all the 
antecedents of the visible signs of the mensual office. 

This is true in the general, but I deny not that the first blow 
may be struck at her health by suppressing her catamenia. Yet, I 
think, this is a rare case. Certainly it is a rare case ; as far as 
my opportunity for observation has enabled me to judge of it. 

For example, I have known many to lose their catamenia by 
severe application of the mind to studies. Many to lose it in 
consequence of catarrhs, fevers, consumptions, &c. &c. It is true, 
also, that I have many times been consulted on account of a sup- 
pression of the evacuation from cold, and from other slight causes. 
Yet, out of the vast majority of these cases, there have been very 
few who had any lasting trouble from the suppression; inasmuch 
as the next operation of the periodical cause being perfect, the 
evacuation has been regularly restored. 

It is easy for you to understand, however, why it happens that 
a sudden suppression of the menstrual flow, in mild cases, or at 
the very commencement, or in the case when a suppressing cause 
has been applied just before the apparition, should lead to a long 
train of morbid actions. 

A young lady, in consummate health, wished to go to a ball. 
But, unfortunately, in the afternoon, before the time for dressing 
arrived, she was seized with her courses, which were generally 
profuse ; and she began to fret at the occurrence, as she was afraid 
to appear at the gay scene of the dance, situated as she was. 
Her nurse, an old and confidential servant, much attached to her, 
said, in order to quiet her grief — "My dear, if you won't tell 
on me, I will arrange it so that you shall go to the ball." "Oh! 
dear nurse, do, and I'll love you for ever." The nurse brought 
a large tub full of fresh cold water, and bade the blooming girl 
sit in it. She did so: the menstrua disappeared. She went to 
the ball: came home before the end with a blinding headache, 
was attacked with a brain fever, lost her bloom, and her embon- 
point; and now, at the age of near fifty years, still feels the mise- 



352 PUBERTY. 

rable effects of such a scandalous dereliction on the part of the 
favorite and confidential servant. 

The uterus and the ovaria, and all the branches of the hypo- 
gastric, the sciatic and the ovaric arteries, were full — it was full 
tide with all that system of vessels — the accompanying nerves were 
all ripe and rife with the periodical excitement. The cold hip-bath 
produced instantly a spasmodic closure of the excreting orifices 
in the womb, and the uterus and ovaria became instantly the 
seats, not of an out-flowing affluxion, but of intense engorgement, 
which, reacting as a disturbing force upon the cerebro-spinal sys- 
tem, laid at once the train for years of ill health. That lady's 
whole life was rendered a scene of bitterness — of vapours and 
caprices by that single hip-bath. It shocked her nervous system 
ruinously. 

Many women, who were in the full flow, have sent for me, to 
say, the flow had suddenly ceased, from wet feet, from cold 
drink, from cold bathing, from pathema mentis, &c. &c. I have 
found them in agonizing headache, neckache, backache, nausea, 
courbatisme, throbbing pulses, and the most exaggerated calorific 
power. 

Such cases do not excite in my mind any solicitude for the 
safety of the patient. A venesection, an aperient emollient 
enema, a dose of castor oil, some camphor and opium, made into 
pills; these are usually followed by remission of the distress. 
The constitution is again brought into obedience to the laws of 
healthy innervation. The next Graafian follicle fills, rises to the 
surface, bursts, and the mensual hemorrhage goes on, at the due 
point of time, as if nothing had interrupted for a moment the 
regular play of the functions. So often have I found this repre- 
sentation of the case to be carried out in the action of the organ- 
isms, that I fear not to allay the alarms and misgivings that arise 
in the mind of the patient, or her friends, with assurances that 
nothing is to be apprehended from such incidents in the health. 

Nevertheless, interruptions of the monthly efflux, produced 
suddenly, as above supposed, may leave the whole reproductive 
apparatus engorged, and even subacutely inflamed. The cur- 
rents introduced into them by the spermatic and uterine arteries, 
and the branches of the ischiatic ; and the nerve streams that ac- 
company all these vessels as their regents and moderators, — these 
are disordered in their very structure, crasis, and chemical con- 



PUBERTY. 353 

stitution, and the next period of elimination may fail, because the 
ovarian stroma is become unhealthy. But this ovarian stroma — 
this vitelliferous, and therein germiferous organ, whose import- 
ance I proclaimed in my second letter, has now become a 
disturber of the constitution. Its nervous connection and rela- 
tion to all the plexuses and nerves of the whole splanchnic sys- 
tem, enable it to call them into sympathizing disturbance, and 
the health is overthrown. The emulgent artery, the cceliac, the 
mesenteries, and all the concomitant cortege of nerves are dis- 
ordered, and now we have disordered renal action. The vast por- 
tal system no longer plays its healthful part in the eliminations for 
w 7 hich it is provided and appointed. Emaciation, opaque skin, 
dyscrasia of the blood, palpitation and irregular action of the 
heart, with consequent morbid states of the innervations proceed 
from bad to worse, and w T e behold the victim of a checked men- 
struation laboring under all the complications expressed in the 
term chlorosis, or green sickness. But if all this may come from 
a check of an established menstrua, a fortiori, it may spring from 
a hindered, or prevented one. 

If the mass of the blood becomes affected with dyscrasia, from 
whatever cause, we have at once a diminished power of the ner- 
vous system, whose force, whose product, (the neurosity,) is the re- 
sult of the contact of oxygen with the matter of the brain. I have 
not forgotten, that though neurine and oxygen give out neurosity, 
there may be qualitative differences in the neurine, and quantita- 
tive differences in the oxygen. That a brain and nervous system 
may be good or bad, healthy or sickly, vigorous or feeble, but 
all these differences may, to a certain extent, depend upon the 
qualities of the blood, its capacity for oxygen, or for heat, its pres- 
sure, its momentum. The nervous system, though it be the 
essential Ens, is produced from the blood, out of which all the 
solids of the body are made and constituted into organs. 

I have no doubt the brain itself is frequently altered in its 
density, in its perceptivity, and its power to extricate neurosity 
for the innervative acts of the economy; in some cases acquiring 
a double portion of such faculties, and in others nearly losing 
them; when lost, it is death. There is a hypemeuric as well as 
a hyponeuric health, as stated by Dr. Cerise. 

Since the introduction of the process of etherization, in surgery, 
w T e see abundant examples of the modification of the powers of 
23 



354 PUBERTY. 

the brain and nervous system made by that agent. M. Flourens 
has shown that inhalation of ether, to a certain amount, suspends 
first, the action of the hemispheres, next that of the spinal marrow, 
next the quadrigeminal tubercles, then the cerebellar lobes, and, 
lastly, the medulla oblongata, which last he regards as the 
nceud-vital. As long as the nceud-vital remains unaffected by the 
ether, respiration goes on, and the other parts of the brain may 
recover, because the nceud-vital being the seat of the respiratory 
power, it can compel the oxygen of the air to enter into the blood, 
and arouse the rest of the cerebro-spinal axis from the insensibility 
into which the ether had plunged it. If the noeud-vital becomes 
engourdi, respiration, or oxygenation of the brain ceases, and the 
animal is dead. You see then that you can in a moment render 
the brain hyponeuric by ether, as you can also render it hyper- 
neuric by champagne or nitrous oxide. 

I have no inclination, and, indeed, it would be out of place in 
this letter, to enter largely into explanation of the state of the 
system in chlorosis. Chlorosis is often something more than 
ansemia; it is often glandular disease — and is connected with va- 
rious states of hepatic and intestinal disease. What I have said, 
I have said with the design of inviting you to reflect upon this 
important question, viz. : What are the evils to be feared from a 
puberty imperfectly effected and ignorantly conducted ? My repre- 
sentations above, ought, I think, to show you that the puberic age 
is one that deserves to be carefully watched and wisely treated. 
But certainly, in this country, at least, too little regard is paid 
to the dangers of the crisis, and when the threatening conse- 
quences of mismanagement or misapprehension have become 
startling, those fatal mutations are attributed to some trivial cause, 
and the victim passes away to the sound of the passing bell, and 
no increase of knowledge, acquired by such a mournful expe- 
rience, stands in the way of the next victim to a management as 
unwise and as thoughtless. 

I find that I have, in my letter on puberty in girls, lapsed 
into a discussion of some points of the doctrine of menstrua- 
tion, in which I have anticipated observations more appropriate, 
perhaps, to that special topic — but puberty in girls, after all, has 
reference chiefly to the establishment of the menstrual office, and 
I could not well avoid falling into such a train of thought. I 
wished to show you that if you do not take wise care of the health 



PUBERTY. 355 

of the growing females of a family committed to your care, as 
physicians, you will have the pain to witness their early subjection 
to dangerous and fatal disorders, or else to see them, even after the 
puberic phenomena shall have been all made manifest, and the 
age of puberty indeed past, suffering those derangements of the 
health which serve to render them useless to their friends, ineffi- 
cient as the heads of families, and unfit to encounter and discharge 
the stern obligations and duties of life. Many are the examples 
I could cite from my memory of the persons who, even after being 
married for years, and after having been regularly menstrual, still 
continued to labor under the effects of a badly passed puberty; 
showing these effects in an over excitable circulation, excessive 
nervous susceptibility, dysmenorrhea — though regularly men- 
strual — sterility, and the impatience and discontent that neces- 
sarily w r ait on feeble health and disappointed expectations ; some 
recovering completely under a careful treatment, and others falling 
into weakness, becoming, at last, victims of consumption, menor- 
rhagia, or other disorders of which the foundations had been laid 
in an improperly conducted physical and moral education. 

As to our own fair countrywomen I think it is true, that, as a 
general rule, the women of the United States break very early. 
I appeal to your own observation for support of this assertion. A 
lady here with two or three children is generally without color — 
pale — and fatigued, attenuated. Perhaps this early break-up of 
the constitutional force of females may be, in part, attributed to 
the nature of our climate, which, from the violent and rapid re- 
vulsions of its temperature, moisture and pressure, as well as from 
the intense force of its light in summer, is more exhausting to the 
life-powers than the cooler and more steady skies of Europe, 
where the women certainly preserve their youthful appearance to 
a later period than here. Those of you who reside in the south- 
ern States will have observed the very striking difference in the 
appearance of persons who have spent the summer in the North 
and those who have waited during the hot months, in Georgia, 
Alabama, and the other southerly regions of the United States. 
Having spent the early part of my life in the South, I was accus- 
tomed to see my friends and acquaintances return from the North 
at the close of the hot season looking ruddy and healthy in com- 
parison with the fatigued and exhausted aspect of those who had 
draw r n out the long summer season at home — and I am sure that 



356 PUBERTY. 

no one can arrive in our ports, in August and September, from a 
trip across the Atlantic, without being struck, and even painfully 
struck, with the air of ill health that is visible in the faces of the 
crowds on the wharves and streets of places so far to the north as 
New York, and even Boston. The cold weather of winter and 
spring restores to them the hues of ruddy health, in order that 
by the close of the ensuing hot season every body may be again 
pulled down, to use an expression much in vogue. 

The western coasts of Europe do not possess such brilliant 
skies as ours. The veil of mist or cloud from the Atlantic, that is 
almost always spread above their heads, prevents the excessive 
radiation of solar light and heat, and the powers of the body are, 
consequently, not so exhausted by over-stimulation from these 
causes, as exhibited in the hurried pulse, the profuse diaphoresis, 
and the almost universal bilious or sallow hue, acquired by the 
complexion on this side. 

If I am not incorrect in attributing to the brilliant skies of the 
United States morbific powers of a most inconvenient kind, then 
I am surely correct in the opinion that young girls approaching 
and passing through the puberic crisis, ought not to be incau- 
tiously exposed to those influences. I speak only of those whose 
condition may seem to require your counsel, and not at all of 
those (the infinite majority) hardy and healthful people, who 
never give cause for apprehension as to their sanatary condition. 

Your delicate patient requires light as one of the conditions of 
health, but not too much light. I have already, in my putative 
conversation with Miss Helen Blanque, in my XII. Letter, ex- 
pressed my opinions as to the necessity of light as a condition of 
healthful life, and I have no reason to distrust the sentiments 
therein expressed. 

But an incautious exposure during the summer heats, is ex- 
ceedingly enervating. Such exposure excites the movement, of 
the blood, and augments too considerably the calorific power of 
the lungs. It produces a quasi feverish state of the body, which 
is only kept down by copious perspirations, that exhaust the 
activity of the cutaneous capillaries and nerves, and introduce 
derangements of the secretions depending on the termini of the 
great splanchnic or digestive vessels of the abdomen. All those 
secretions are effected at the expense of the cceliac and the two 
mesenteric arteries and their termini, and it is undeniable that 



PUBERTY. 357 

the sanguine circulation in those vessels and the ports?, has a 
close connection with and dependence on the cutaneous organ. 

Do I recommend that the young girl at the season of puberty 
should lead an idle and inactive life ? Far from me the thought. 
I repeat, that I think every such person should be exercising in 
the open air, to the extent of walking many miles daily. But 
from the 20th May until the autumnal equinox, that exercise can- 
not be well taken later than nine o'clock in the morning, and at 
hours when the sun has descended so near the horizon as to lose 
the power of a too violent radiation. 

There are a freshness, and humidity, and coolness in the early 
morning air, that impart greater vigor to the constitution than 
that of later hours. Early rising and early walking, then, ought 
to be recommended to all such persons as are directed in a course 
of training for health. 

But early rising is unendurable, except for those who retire 
early to rest. They go hand in hand with each other. 

The young girl should be at rest before ten o'clock at night, 
then at five o'clock in the morning she will be fitted for a walk of 
two or three miles ; it is easy to walk three and a half to four 
miles an hour. Such a walk in the early morning air, after eat- 
ing a biscuit and drinking a glass of water, would give appetite 
for breakfast and power for its digestion. A walk of three or four 
miles in the evening, before and after sunset, would furnish the 
requisite amount of out-door exercise, say seven or eight miles a 
day. An amount far, I fear, beyond that taken habitually by 
the young portion of the sex in the United States. 

I am much accustomed to make inquiries on this head ; and I 
lament to learn, as I often do, that young persons of the class un- 
der consideration, frequently pass many consecutive days without 
walking a mile per diem in the streets, or roads, and paths in the 
country, and even without going out of the house. 

Physicians are the health officers of society. I would that phy- 
sicians, as a body, were awake to the importance of so guiding 
the public mind in all topics connected with the conservation of 
health, as to exert the whole influence of the profession, a great 
influence, in impressing upon the public mind clear and sound 
notions in regard to those hygienic uses and appliances which the 
public either know not, or overlook, perhaps, in the hurry and 



358 PUBERTY. 

cares and embarrassments of the business and occupations of the 
world. 

It appears to me that common sense and daily observation 
ought to teach the necessity of exercise as a means of preserving 
the health. The social condition of man has, in some degree, 
changed his nature, for by nature he was doomed in the sweat of 
his brow to eat his bread. Society has enabled him to eat bread 
without perspiring for it, and the luxurious and effeminate man- 
ners of the times seem likely to grow more and more Sybaritic 
under the labor-saving results of the improved machinery of these 
modern times. 

A physician ought to exert the intellectual power, which, by 
his position in society he is presumed to possess, in protecting 
society against the evils of ignorance on hygienic subjects. 

Forty-thousand medical men in the United States should not 
allow their day and generation to pass away without leaving some 
signs of progress, some amelioration of the condition of society, 
beyond the mere restorative results of their therapeutical prescrip- 
tions. I fear that so much intelligence, so much power is nearly 
restricted in its beneficence to the cure of the sick alone, whereas 
it ought to be capable, if not of preventing the onset of disease, at 
least greatly to lessen the number and violence of the cases. 

In the conduct of those cases where doubts as to the successful 
effectuation of the change into menstrual life cause you to be con- 
sulted, I trust that you will never confine your intentions to the 
mere point of compelling the young person to have a show. In- 
deed, if you take up just views of the nature of the catamenial 
office, I am persuaded you will not do so ; since you will know, 
that, if she produces and evolves germs she will menstruate; while, 
if she does not produce them, you cannot cause her to menstruate. 
You can make her bleed, perhaps; nay, you can, very certainly, 
make her bleed by leeches, with cups, or with the lancet; but 
every tyro knows, that to bleed a woman every twenty-eighth day, 
is not to satisfy the physiological demands of nature in menstrua- 
tion; because nature does not require merely the loss of so many 
drachms or ounces of blood, but she does require that the impor- 
tant organs should all enjoy the power of exercising the functions 
appurtenant to their several natures; when they do so, the economy 
is healthy, when they fail therein, it is sickly. 

The prime interest in the conduct of the case is first, to explore 



PUBERTY. 359 

and understand its nature and all its peculiarities and wants. This 
seems to me by no means a difficult task, provided one goes the 
right way about it. For example, suppose a young person pre- 
sented to you for examination, and that you proceed in manner as 
follows : 

"What is your age, child?" 

"Fourteen years, sir." 

"Are you sick?" 

"No, sir. They say I'm sick, but I don't feel so!" 

"Have you ever been sick?" 

"Yes, I had measles, and scarlet fever, and whooping cough, but 
that was a long time ago. I have also had some bad colds, occa- 
sionally." 

" Do you feel strong and healthy?" 

"No, not very; but I'm not sick though." 

" Are you as fat as ever you were, or are you thinner than you 
used to be?" 

" Why, I am thinner, I suppose, but not much." 

"Do you go to school?" 

"Oh, yes, I go to 's school." 

"When does school let in?" 

"Eight o'clock in the morning." 

"How long before it lets out?" 

"Half past one." 

" That's five hours — a long session! but what do you do all that 
time?" 

"I am studying my lessons and reciting them." 

" What lessons ? What is your daily work in school ? Tell me 
all about it? Tell me the whole course of a day's schooling?" 

" Why, when we assemble, we have prayers, then a chapter in 
the Bible, then a hymn, and close with a short prayer; after which 
I recite my lesson in spelling, then English grammar, and next, 
one in geography." 

"Why, when do you get all these lessons?" 

"In the evenings, at home." 

" Do they keep you late up?" 

" Until nine or ten o'clock, only." 

"Well, what comes after geography?" 

" Oh ! I write copies, and then study my Latin grammar. When 



360 PUBERTY. 

I've got the lesson I conjugate the verb, and decline a few nouns 
and recite some rules." 

" What next?" 

" I study fifteen or twenty lines in Virgil, which I construe for 
the teacher." 

"Does he make you parse it and scan it ?" 

"Oh, yes sir, to be sure, always." 

"Have you any other studies?" 

"Yes, sir, French." 

" And you commit to memory in French, too?" 

"Yes, and read, and translate, and write exercises." 

" Anything more ?" 

"Algebra." 

"What, algebra? Oh!" 

" Oh, yes sir. And then we have lessons in drawing." 

" What do you draw ?" 

" Landscapes, maps, &c. &c, as figures, flowers, and what 
not." 

"Any music?" 

"I have a lesson on the piano three times a week; but mother 
makes me practise two hours every day, one before I go to school 
and one in the evening." 

"My poor child, I am sorry for you." 

" Why are you sorry for me, doctor ?" 

"I am sorry to find that you work so hard." 

"Oh no, sir, I am delighted with it." 

" No doubt ! no doubt ! but it will ruin your health. I don't be- 
lieve there is anything the matter with you now but schooling. 
Bless your dear little heart, you ought to be chasing butterflies, or 
training flowers, or weaving them into pretty coronals, such as 
white morning glories, pale as yourself; or you should be dressing 
dolls, or galloping the pony, or dancing, or dawdling. You must 
not do so much work at school, and you shall not, if I can prevent 
it. But come, tell me about your health. Do you walk out to 
Schuylkill every day? or as far as the College?" 

" Oh, no, I've no time ! Didn't I tell you I go to school at eight 
o'clock and come out at one ? and then I have two hours in school 
afternoons." 

"The d—1 you have!" 

" What did you say, doctor?" 



PUBERTY. 361 

" Nothing, only an ejaculation; an extorted one. When do 
you get to bed, my dear?" 

" About ten o'clock, or soon after ten." 

"Do you sleep soundly?" 

" Not always, I often get frightened in my sleep with what they 
call nightmare." 

"Not to be wondered at. I should think your poor little head 
would be too tired to sleep soundly, and that you would have a 
nightmare in the shape of a monstrous folio grammar, or diction- 
ary with a pair of spectacles as big as two moons on its nose, 
staring at you from a pair of dead looking eyes. Do you eat 
hearty breakfasts?" 

" No, doctor, I have but little appetite for breakfast. I take some 
cold water and a slice of bread and butter, and make haste to 
school after my piano practice, for I am so tired in the morning 
that I can hardly get up, and that keeps me late." 

"How's your dinner?" 

" Oh, I like pies and preserves, but I can't bear meat, and as for 
soup, I hate it." 

"Oh, dear! poor child ! Alas for you! Come here, sit by me, 
and let me feel your pulse. Don't be frightened. There, now. 
Your pulse beats eighty times a minute ; and you are fourteen years 
old you said. You are breathing twenty times a minute. Are 
you oppressed in breathing?" 

"What do you mean, doctor?" 

" I mean to ask if you can draw a great long breath. So — try 
it now." 

"Why, it hurts me." 

" Where does it hurt you?" 

"Nowhere in particular; it is rather disagreeable than painful. 
It seems like weakness and a tired feeling." 

"It does not make you cough, does it?" 

"No, doctor." 

"Have you headache often?" 

" Oh, yes, my head always aches when I wake in the morning; 
and if I run, or skip the rope, it aches, and swims, and beats 
dreadfully." 

" I should think so. When a body is pale like you, any exercise 
makes the head beat and ache. Do you remember ever to have 
had red cheeks?" 



362 PUBERTY. 

"Oh yes, doctor. My cheeks, when I was ten years old, were 
red as the inside of a conch shell." 

" Have you grown much of late?" 

"Oh, monstrously; I have grown half a head taller in eighteen 
months." 

"Where's your mamma?" 

" She's up stairs." 

"Go, call her to me. You need not come back yourself. I 
shall send for you when I want you." 

"Pray, madam," said I to Mrs. , "what do you suppose ails 

Miss Mary?" 

" I can't imagine what it is that has changed her so, doctor. She 
used to be the healthiest child in the house, merry as a grig, 
always singing and dancing ; but now she is dull and moping, and 
has grown pale and thin, and has no natural relish for food. I 
suppose it is a change working in her. Don't you think so, doctor? 
She is fourteen !" 

"I cannot tell. It is probable that her constitution is making 
an effort in that way ; but I wished to ask you some questions 
that I did not like to address to the child herself. Can you tell 
me what is the state of her digestion?" 

" As to that, she is very irregular, sometimes costive and then 
again yery much the reverse, and that without any evident cause 
for it. I suppose it may be owing to her living, for I can't get 
her to eat any good food. She likes nothing but cakes and sweet- 
meats, candies, and all such trashy food." 

"Is there any change in her temper?" 

"Yes, doctor. She is more irritable and cross than is her nature 
to be, and she is easily put out ; the least thing makes her cry. 
Indeed, we find her very much changed of late." 

" She has never been unwell yet, has she?" 

" Once, about four months ago, her nurse told me she had seen a 
very slight mark of change, but it was merely pour marquer, not 
anything of consequence, and has not returned since. We are 
very much concerned about her, for we find she is growing pale, 
thin, and lounging, and cannot be persuaded to walk out, nor 
does she like to go out in the carriage. Nothing pleases her so 
much as books. If you give her a book and a sofa she is perfectly 
satisfied. But I fear she reads too much, and that her lessons are 
exhausting her." 



PUBERTY. 363 

" My dear madam, I think if I might venture to speak Latin, I 
should say rem acu tetigisti — you have hit the nail on the head ; 
and I am much afraid you will destroy her health unless you 
make some change in her mode of education." 

"But, doctor, that is very difficult. You know that schools are 
managed by classes, and that we must educate our daughters ; they 
must be with their classes, you know. They cannot be always 
put back ; it disheartens them. What is one to do in such a case ? 
You wouldn't have her brought up in ignorance, would you?" 

"No, certainly, not in ignorance, but I should much prefer to 
have a daughter healthy, sweet tempered, sensible, and beautiful, 
without Latin and algebra, and grammar, than to have one ever 
so advanced in her humanities, with her health ruined, or, perhaps, 
lying under a marble urn at Laurel Hill." 
"Why, doctor, you shock me." 

" I intend to shock you, madam! I know what love you bear 
to this dear child. I am aware that her great beauty and intelli- 
gence, and sweetness of temper render her not only your admira- 
tion, but that also, of all your friends, and I am grieved to see 
that, in the impetuous hurry and press of her intellectual and 
moral education, you have wholly lost sight of a part of her edu- 
cation, without which the others are of no value, of no effect, but 
rather poisons, that destroy. I wish to shock you; I wish you to 
learn that unless you change the treatment, you will lose her. 
She will die, madam!" 
"Are you serious, sir?" 

"Serious, dear madam? Serious! I am more than serious, I 
am grieved. I saw a sweet creature within a year, an only 
daughter, an only child, indeed, worth to her parents more than 
a chrysolite as big as herself, done to death by mere schooling. 
Why, can you not perceive that if this child of yours had nothing 
to do but grow and enjoy herself, she would be as beautiful as a 
houri, instead of breaking one's heart, as she does now, with that 
painful conviction of uncertain health, that is inseparable from a 
look at her." 

"What are we to do, then, sir?" 

"Do! dear madam? What are you to do? Educate her as a 
sensible woman would educate her dauo-hter." 

"But every body insists on her learning all these things! All 
the girls learn Latin now." 



364 PUBERTY. 

"I tell you that to rack her little brain learning Latin is non- 
sense. She can't learn it, in the first place. She can only try 
till it makes her sick, and then she'll give it up. Tell me, now, 
who of all the women in America or England have learned Latin! 
Nobody. Madam Dacier learned Latin I grant you, but she 
would have been much better employed learning to make pud- 
dings and to keep house." 

"Ah, doctor! that's the way you men all talk ; you think that 
women are inferior creatures, and that they cannot learn what is 
very essential to the education of every gentleman." 

" Far from it. Instead of thinking that women are inferior crea- 
tures, I for one look upon them as infinitely superior in many 
respects of their understanding, and altogether in morals, to men. 
But their lot is cast for them ; men did not make it ; God made it. 
They cannot, in the present state of the world, and probably never 
will, participate in the affairs of nations or municipalities, be- 
cause, by the very nature of their moral and physical constitution, 
they are bound to the horns of the family altar; if they let go, 
they soon become captive to some tipstaff of an Asmodeus or 
other evil spirit, who, like constables and tipstaves from the lower 
world, are wandering up and down in the earth, seeking whom 
they may devour among unemployed ladies. I do not believe that 
women are inferior beings. I regard them on the contrary as 
the ministering angels of the race; as the source of happiness 
and virtue, as well as its reward. But in order to be educated 
it is surely not necessary to have a smattering of Latin and 
Greek. What is it to Mary that Horace or Virgil wrote their 
verses, or Tacitus his annals, or Terence his Comedies ? She can 
read Pliny's letters better in Melmoth than in Pliny, for Mel moth 
is a better writer than his author; and as for Tacitus and Virgil, 
Davidson and Murphy will not rack her brain like the Arma vi- 
rumque cano, or the Urbem Romam a principio reges habuere. 
Mary wants to grow — she wants to grow up to be a woman — ■ 
not to peer into the amatory elegies of Tibullus and Catullus, 
or pry into the detestable stories of Apuleius the Madauran. 
What does she want with algebra? Shall she rival Leverrier or 
Arago? The only arithmetical calculation she requires is the re- 
lation between one dozen eggs at twelve and a half cents, and 
three dozen eggs at the same rate ; and the unknown quantity- 
she ought to look for is, the proper gentleman whom the fates 



PUBERTY. 365 

and sisters three have in store for her as her future lover. Ah, 
madam, the ancient literature was much of it lost at Alexan- 
dria, and if that blessed St. Omar, who burned it nearly all up, 
had been lucky enough to get all the Latin school books into the 
bargain under the baths, — I can't say I should be glad for my 
own particular sake, for I should not ; but I am very sure the whole 
rising generation would be glad to contribute all their coppers and 
ten cent pieces to make a statue for the shrewd Caliph. The labor 
of life is a great labor and a long one, but there is no toil like 
that of an over-tasked schoolboy or schoolgirl. As for your child 
it is true she ought to be educated, but let her education fit her 
for her duties in life, not destroy her health and beauty. Lady 
Jane Grey and Queen Elizabeth could read Latin, but they had a 
different destiny from that of a republican's daughter. Let those 
who are likely to use to advantage the more elaborate parts of early 
instruction, let them have it, but do not kill them to get it. Igno- 
rance is always to be eschewed — but if I was destined to be a 
doctor, what use was there in making me study logarithms or 
lunar distances, or compute the orbit of a comet ? I was brought 
up to my trade — let Mary be brought up to her trade. What is 
that? It is taking care of a family — wisely, happily, elegantly; 
to do that, let her learn the world and the ways of it — not too 
much, though. Educate her in truth and the love of it — in piety 
which is the best grace of the sex. Teach her administration 
— domestic administration. Teach her to have a place for every- 
thing — and to put everything in its place. Make her an econo- 
mist — not a miser. Teach her to be saving. Do not impress 
upon her the scoundrel maxim, as Thomson calls it, 

" A penny saved is a penny got; 
Till from her board it drive both plate and pot." 

Teach her the great virtue cleanliness and tidiness ; improve her 
natural propensity to adorn her person under subjection to the 
simplex munditiis rule. Let her make herself beautiful and 
pleasing. Of all things let her be charitable and kind — for 
charity overcometh all things. Mr. Clay, Mr. Webster, Colonel 
Benton and Mr. Calhoun will take care of the politics: General 
Scott and General Taylor will take care of the soldiers ; let the 
daughters take care of the children, and learn to be bright at 



366 PUBERTY. 

the breakfast table, elegant at dinner, enchanting as pourers out 
of tea, and the ornaments and grace of the saloon." 

"Ah, doctor! I see how it is; you pretend to be a great admirer 
of the sex — but, like all the rest, you would condemn them to 
an inferior place." 

"I! — I condemn them to a lower grade of rank in the body 
social? Not I. I am a convert to Burdach's views. I see in 
them the race, and we men but the supplements. They are the 
queens in the hive — we but a sort of mixed medley of drones 
and workers. It is far more noble, in my opinion, and far more 
elevated, to shed the benign influences that ever flow from the 
reign and dominion of a fine woman over the family and through- 
out the circle of society to which they extend, than to shatter men, 
women and children, and churches by shelling the enemy out of 
Vera Cruz, or giving them ' a little more grape' at Buena Vista. 
No, madam, I do not disparage the sex by confining them to the 
domestic duties, but I rather magnify them and make them honor- 
able. But let us change the subject, or rather let us return to 
our subject, which is Miss Mary's health and the conduct of it." 

"Well, what must we do, doctor?" 

"It is now the end of June. The heats of summer are come, 
and the dog-days will soon be here. It ought to be a general 
holiday. Take Mary to the mountains or to the shore. If you take 
her to the mountains it is well, if to the shore it is perhaps as well. 
Among the mountains she will walk on uneven places, up hill 
and down. The air is pure, the streams clear and rapid, and 
there is no malaria; walking among hills is admirable exercise; 
it compels the blood to reach the most distant points of the cir- 
culation, and drives it from the deepest recesses of the body. 
It augments the development power pari passu with the invigo- 
ration of the appetite and digestion. There is shade in the deep 
valleys and dark ravines, and to walk by the side of running 
waters, and listen to the plash of their falls, imparts a delicious 
calm to the soul, while the physical powers, as in a sort of 
waking sleep, seize the opportunity to renew and restore their 
wasted strength. 

" Take her to the shore. There you have the benefit of the 
breeze from the sea, and the ever varying spectacle of the ocean's 
surface presenting ever new and pleasing sources of sensation. 
The sounding strand, the leap of the breaker, the ebbing and 



PUBERTY. 367 

flowing roll of the waves on the sands ; ships heaving in sight and 
slowly disappearing ; company, conversation, music, the dance, 
and above all the bathing in the animating surf, present combined 
means of increasing the health and spirits, that are, perhaps, not 
certainly, equal to those derived from a visit to the mountains. 

"If you take her to the hills, let her walk, as much as you dare — 
at least six miles daily, and if the country is very hilly, that is 
more than equivalent to a walk of eight or ten miles on level 
roads. 

" If she goes to the shore, be careful not to allow her to bathe 
too much, surely not more than once a day ; nor too long, not 
more than fifteen or twenty minutes each time. I am quite con- 
fident that those who stay very long in the water are weakened 
by it. They generally come away from the coast thinner, and 
shrunken, and lighter than when they go there. 

" The sea bath has great power on the body by its saline nature, 
which is stimulating to the whole skin ; by the motion and effort 
that those use who bathe in a strong surf ; by the delight which the 
dash of the wave communicates, and by the gayety and joyous 
feeling engendered by the company of the bathers. 

"If she remain very long in the water, her hands and feet will 
be shriveled or puckered when she comes out, and it will be after 
a long time and with considerable effort that the blood w T ill again 
reach to, and distend the tissues on the surface, and the most dis- 
tant parts of the limbs. In order to receive any benefit from the 
bath, there ought to be some degree of such a reaction, but it is w r ell 
nigh morbid, when it comes too slowly. A person coming from the 
bath and remaining cold, or even quite cool, for half an hour, has 
been in it too long. Many persons suffer from the bath such a 
concentration of the blood in the great cavities, as the chest, and 
head, that they find themselves oppressed in breathing, or giddy 
and affected with headache, upon leaving the w r ater. I have seen 
many such coming from the bath unable to see, and with intense 
cephalalgia, and only relieved by the act of vomiting; all which 
was dependent on the rushing of the blood to the brain, where it 
had been driven by the cold water from the extremities and the 
skin. 

"Take care of Mary's diet. 

"Let her eat beef, mutton, or poultry, once a day; don't give 
her the sort of vegetables so correctly denominated in this coun- 



368 PUBERTY. 

try, trash. Indeed you ought to give her her eatables with one 
sole view — that is, to nourish her, to make her grow, — to make 
her stronger and healthier. Don't allow her to swallow a morsel, 
merely because it tastes good. It would not be amiss in educat- 
ing her, to educate her palate. I wish you would buy her a copy 
of Brillat Savarin's Physiologie du Gout ; it would do her more 
good, and make a better woman and wife of her than Massillon, 
or even Telemaque, or Paul and Virginia, for it would teach her 
what every woman ought to be taught, the difference between an 
elegant gastronomic taste, and that horror of horrors, foul-feeding 
in a lady. Only think! only think of a lady eating tripe — or de- 
vouring fried haslet!! It is surely but one step above the dinners 
of the Bosjesman's. Take care of her dress; when the weather 
is hot, don't heat her; when it is cool, or cold, don't let her be 
chilly for want of a flannel petticoat, or a mousseline de laine, 
instead of a gingham, or fine print. 

"No body is well who has not a proper state of the bowels. 
The upper bowels are well enough for most people. It is the 
large intestine that is the seat of costiveness. You must avoid 
that. How? By regulating her diet. Bran bread regulates the 
bowels, keeping them soluble. So do mush and milk, baked 
apples and milk, ripe sweet fruits, food not too much salted. We eat 
too much salt, in this country, it heats the blood and over stimu- 
lates the digestive organs. I believe half the charm of the French 
cuisine lies in the perfect apportionment of the salt. No spices. 
Not too much drink. Every body drinks too much. In the cities 
they drink too much iced water. Half a tumbler of spring 
water slakes thirst more than a tumblerful iced down to 45°. 
If her bowels are slow, you can make her take a pill of aloes 
and soap, or a pill of aloes and rhubarb ; one grain of aloes to two 
grains of rhubarb. Such a pill taken daily early in the morning, 
or on going to bed, will keep the bowels regular enough. 

" Perhaps there is no pill to be found that is preferable to Lady 
Webster's pill, called also Lady Crespigny's pill, and the Dinner- 
pill. It is made after the following formula : 

R. — Aloes, 5vj. 
Mastiches, 3ij. 
Ros. rub. 3ij. 

Syrup absinthii, q. s. M. ft. massa in pilul. no. cc. divi- 
dend. 



PUBERTY. 369 

" One or two of these pills, taken from half an hour to an hour 
after dinner, will rarely fail to procure an evacuation without 
purging. 

" Don't suffer her to be violently excited ; take every precaution 
to keep the mind not stupefied, certainly, but in a calm and com- 
placent mood — rather gay than grave. 

" Examine her books before you let her read them. Keep out of 
her hands the Paul Cliffords and Ernest Maltravers, and all that 
sort of passionate novel reading. Walter Scott will never do her 
any harm. On the contrary, he is always on the side of virtue, 
decency, and order ; his passions are not very passionate, except 
perhaps, Dirck Hatteraick's case, and he was a mere brute. But 
as a general rule, works of fiction are of little value in the moral 
education of the young ; they spoil the taste for more useful studies ; 
and are for the most part dull and uninviting, except they be sea- 
soned with the wild, the terrible, or the passionate, in revenge, in 
mysticism, or in love. 

"It is surely practicable, while her mind is evolving itself, to 
educate it and cause it to develope itself in a particular direction. 
You do not deny that she might be educated to become a devoted 
sister of charity, a calm, unirnpassioned country girl, or a fantastic, 
uncontrolled opera dancer. 

" If you educate her for the persistent zeal of the conventual life, 
for the dull complacency of the farm life, or the excitement and 
passion of the spectacle, do you not modify her whole nervous 
system by these several modes of education. Is it not true, in 
morals as in gardening, that 'just as the twig is bent the tree's in- 
clined,' and is there the shadow of a doubt, that you could so edu- 
cate your daughter as to make her a pattern for a nun, a milk- 
maid, or a prima donna? 

"If there be no doubt as to the power of the moral educational 
processes, to give such or such a bias and propensities to the 
mind, then you ought to consider what is the bias it is for her in- 
terest and your own that she should take. 

" If you wish her to be beautiful, steady, sensible, useful, and 
therein admirable, you should take heed to give her all the habits 
that may conduce to such an end of her physical and moral educa- 
tion. Let her know the history of her race ; teach her the lives that 
she may imitate the example of the most illustrious women, illus- 
trious I mean for virtue ; give her a good foundation of geographical 
24 



370 PUBERTY. 

and ehorographical knowledge. Let her learn the uses of figures. 
Give her a competent view of chemistry, that she may understand 
the true nature of the physical things of the globe ; a sketch of 
natural history, I mean not only zoology, but botany ought to be 
clearly understood by her ; the purest and best poets, and writers 
of criticism. The use of one or more foreign languages, chiefly 
French or German, ought to enter into the plan of a lady's edu- 
cation. If she have a positive talent for music, let her be taught 
the use of some instrument and of her voice ; if not, pray don't 
make her ridiculous by a pretension to musical power she can 
never possess. Don't teach her the art of squalling. To draw 
is always a useful accomplishment. But do not let her learn that 
art by halves ; nor not at all if she is without the taste and in- 
clination that alone can give her real success. There is scarcely 
a more useful point in the ornamental part of education, than 
the talent of drawing • it serves pre-eminently to render one's ideas 
of form, dimensions, and distances more perfect. 

" As to the religious part of her education, I have no other w 7 ords 
to say of it, than that a woman who is impious, is impious indeed. 

" I think in this country a woman is not properly marriage- 
ble until she is eighteen, and better so at twenty. If, therefore, 
you commence the literary education in earnest as early as nine or 
ten years, you have eight or nine years of applicable time to give 
to the daughter the elements of her education — to give her her 
school education — by which I mean, the acquisition of a love for 
letters in a proper direction. To think of any one being educated 
at eighteen is preposterous. All life ought to be a continued scene 
of education, and the longest life is too short to allow us to do 
more than ' just to look about us and to die.' 

" As to the medical management of the child, I believe that to 
be a very simple matter. It consists in a wise regulation of her 
diet, and dress, and in a careful attention to the state of her di- 
gestive organs. 

"If you can provide for the regular evacuation of her bow r els, 
without tormenting them with drugs, they will take care of the 
rest of it. Do not allow her to be costive. As for the rest she 
requires to be sustained, not reduced. If in the country she 
should acquire a good appetite, it is probable that the bow^els wiil 
be ipso facto regulated by a proper and full allowance of food ; if 
not, give her some rhubarb ; rhubarb pills, or some elixir-pro, or 



PUBERTY. 371 

some tincture of hiera-picra, very little, however ; the smallest 
quantity that will answer the purpose is the best quantity. 

" She is weak at present. She has grown very rapidly during 
more than a year, and has outgrown her strength. Under such 
circumstances you would not do wrong to give her a small glass 
of sherry or port at dinner, diluted with water, though. There are a 
great many bitters that are useful in supporting the digestive or- 
gans, such as wild cherry bark, quassia, infusion of gentian and 
cascarilla, orbark and cascarilla, or sulphate of quinine, the latter is 
probably the best of them all. But all these bitters are more or 
less disagreeable to young people, and they grow tired of them 
and give them up. If you please you can compel her to take 
them. 

"While it is true that the vegetable tonics are endowed with 
great medicinal power, it is equally true that the mineral articles 
are also capable of increasing the tone of the solids of the body, 
by augmenting the development force resident in the sanguiferous 
apparatus, and its nerves. 

" Among these tonics, the safest and not the least efficacious, are 
those derived from iron. The chalybeates may be taken for an 
indefinite period, and they neither fatigue, nor disgust, nor poison 
the patient. 

" There is a large and free selection to be made out of the nu- 
merous preparations into which iron has been converted for medi- 
cinal uses. It is probable that they all partake more or less in 
the tonic properties of the chalybeate. M. Raciborski, in his 
Treatise de la Puberte, &c, seems to think the most powerful 
and preferable of them, is the article proposed by MM. Quevenne 
and Miquelard, the impalpable powder of metallic iron, procured 
by passing hydrogen on an oxide of iron heated to redness in a 
porcelain tube, which reduces the metal, and leaves it in micro- 
scopic shining particles. This powder of pure iron unites with 
the acids of the digestion, and exerts its peculiar influences, 
whatever they are, with very great certainty. 

" Tw t o grains taken for the dose, and swallowed soon after each 
daily meal, serve in a pure, unmixed anaemia, to restore the crasis 
of the blood in a fortnight or three weeks. Made into pills with 
sugar and gum, they are supposed to keep perfectly well, and 
they are both inodorous, and without taste, provided they be not 
chewed in taking them. 



372 PUBERTY. 

"Procure 200 or 300 such pills, and you shall see what a power 
they have to steady the circulation, to render it powerful, and 
hence to give steadiness, firmness, and precision to the actions of 
the nervous system. I should advise you to give the medicine 
daily for many months. It is not very rare to take it for more 
than a year. I have very good reason, from my observation of 
cases, to believe that if a person, under these circumstances, re- 
covers a good appearance of health and vigor under the use of 
iron, and then at once leaves it off, there is a propensity to re- 
lapse. Hence I insist upon a protracted use of it; and I have 
the less hesitation to do so, inasmuch as I do not regard it so 
much a drug that I administer, as one of the regular elements 
of the bodily constitution. 

" Open your senses to the truth, you shall see with your eyes, and 
hear with your ears, the sound that comes up out of the bosom of 
nature, proclaiming aloud that every violation of the laws of na- 
ture is a wrong. Anybody can perceive that, in a highly polished 
state of society, there are innumerable violations of the dictates of 
nature, which speak to us constantly, and cry out to us aloud. Nu- 
merous diseases are engendered by the constraints and the indulg- 
ences of the bienseance. Make your child, therefore, as natural a 
creature as possible in society; that is the way to secure her physi- 
cal health. Make her also — wise — wise unto the end and destiny 
of her being. I grant you, that being at Rome, we must, in some 
degree, behave like the Romans ; not wholly so; for we may live 
in society, and even be regarded as presentable people without 
becoming victimized, and wholly converted from a natural into an 
artificial condition, either as to temper, manners, or the tone and 
practice of truth and sincerity. 

" As to rest and labor, as to dieting and dressing, as to amuse- 
ments and studies, there is a degree and a time which common 
sense makes clearly known to any one who will reflect. 

" The health, the beauty, and the happiness may be impaired or 
perverted, and even destroyed by educational processes wrongly 
conducted. There is no Procrustean rule by which all capacities 
are to be measured, and it-is the business, and it ought to he the 
sagacity and the skill of the directors of education to discrimi- 
nate among the talents, and propensities, and abilities of those 
who are to be brought up. I shall relieve you from this long 
homily by repeating the words that I heard in the spring of the 



PUBERTY. 373 

year 1813, from the lips of our venerable and illustrious medical 
professor at the University of Pennsylvania, Dr. Rush. Those words 
were spoken in the ears of several hundreds of his pupils. He rose 
from his seat, for his age was great, and his hair white as snow. 
He arose and stood up, and casting his eyes over the large hall, 
looking to the left, and then to the right, and then to those in front 
of him, he said, 'I rise from my seat in order to pronounce two 
words in your hearing; and that you may remember them long, 
and apply them wisely : 

OBSTA PRINCIPIIS OBSTA PRINCIPIIS. 

Oppose the very beginnings of disease.' And now I repeat them 
to you, madam, obsta principiis; oppose the beginnings of disease 
in the child; watch over her health, and when you see that it is 
deranged, call the physician, and he will tell you whether you are 
to do something or nothing. Do not allow her to become slowly 
and insidiously, and deeply disordered, before you take prudent 
measures with her." 

Gentlemen, I have written you a very long letter about puberty 
in girls. Upon looking over it, I fear it will merit the character 
of a letter de quibusdam rebus et de omnibus aliis. Have I suc- 
ceeded in my intention and design ? That design and intention 
was to say why I regard the puberic malady as a malady of the 
blood, arising from a pathological state of the endangium, the 

BLOOD-MEMBRANE. 

If you look through the volumes in your libraries, I apprehend 
you will not find in any of them so concise an opinion, as that 
which I have herein expressed ; and I beg to assure you that so 
far from expecting that such opinion will be accepted by my 
brethren, who may chance to do me the honor to look over these 
pages, I even expect to be condemned as hypothetical and vision- 
ary in my notions on this particular point. To any such reader, 
I would gladly be allowed to submit, that after many years of 
reflection and observation, which happen to have accumulated, 
as to this particular malady, I have been unable to come to any 
other conclusion. I hope there is no person of sensibility, who 
would be indifferent to the opinions of his peers, or his superiors, 
in any walk of life. I freely confess that I am very remote from 
any such indifference, and that I should seriously regret the put- 
ting forth of opinions in medicine, that might be supposed to in- 



374 THE MENSTRUA. 

juriously mislead the young and inexperienced. I have, there- 
fore, to express my hope that, if upon a perusal of this letter, it 
may appear to any of my brethren I am obviously in error as 
to my notion of the endangial disorder, as a cause of the puberic 
malady, such brethren would do me but bare justice, by inquiring 
how it is possible to explain that affection by any other hypothesis, 
seeing, that it is purely a want of innervative force for extraordi- 
nary efforts, while that force is fully and absolutely adequate to all 
the functions of health, while the body is in repose ; all I say, sav- 
ing and excepting the last climax of development force as exhi- 
bited in the production and evolution of ovarian ovules. 

My suppositious conversation with the patient and her mother, 
I thought might serve to lay before you, my young friends and 
pupils, less tediously, not less didactically, a manner of talking 
to my patients, that I have long used. 

I have nowhere asserted that other maladies may not enter into 
the category of the puberic maladies. I now say that when they 
do so, they are pleuritis, rheumatism, hepatitis, gastro-intestinal 
diseases, and, in a word, all the various forms of diseased action 
that may serve to contravene the menstrual power and offices. 
But when they do so come, we are to treat pleuritis, hepatitis, 
rheumatism, &c, and not the puberic malady. That is an en- 
dangial disorder. Farewell. C. D. M. 



LETTER XXVIII. 

THE MENSTRUA. 

Gentlemen : — It is universally known that the female is dis- 
tinguished from the male, not more by the peculiarities of her struc- 
ture, than by those of certain functions, such as child-bearing, 
giving suck, and by the regular elimination at stated periods of a 
quantity of sanguineous or bloody fluid. The functions of men- 
struation, of bearing children, and of providing the aliment for 
them in the mammary glands, are then the three distinguishing 



THE MENSTRUA. 375 

functions of the sex. Yet, though differing from each other so 
manifestly, they are to be considered as intimately allied to each 
other, the one not being possible, as a general rule, without the 
existence of the other two. 

You know already, that the sexual functions are not assumed 
in this country until the fourteenth or fifteenth year, and that 
when they happen to be assumed earlier than the fourteenth, or 
later than the sixteenth year, they are to be deemed precocious 
in the one case and in the other tardy. That individual is to be 
regarded as most fortunate, in whom this occurrence is first 
noted between the age of fourteen and fifteen years. A prema- 
ture eruption of the menstrua is always to be deprecated, be- 
cause it is the evidence of a precipitate development of certain 
parts or structures, while others, not less important in the same 
category are delayed and incomplete. The individual who passes 
at a usual and healthy rate through all the stages of growth and 
development, from infancy up to maturity, is most likely to enjoy 
a healthy and happy life, free from weakness, pain, and the dan- 
ger of premature death. Death loves a shining mark, it is said, 
and those children and youths who astonish us by the early per- 
fection of their structures or their intellectual forces, are snatch- 
ed soon from the world, as the earliest blossoms are ever most ex- 
posed to the chilling frosts of spring. On the other hand, a late 
and procrastinated first eruption of the menstrua, is to be regarded 
as the sign of some weakness or disorder, preventing the mani- 
festation at the average period of life, and always excites painful 
apprehensions as to the security and perfectness of the individual 
in whom it is observed. 

Differences of climate, situation, and condition introduce differ- 
ences in the period of the assumption of these powers. There 
is no doubt that the women of Lapland, the arctic highlanders, 
the women who are brought up roughly to laborious employ- 
ments, and on coarse food, are later in the manifestation, than 
those who reside in temperate or hot latitudes, those who are 
brought up luxuriously, and in whom the susceptibilities of the 
nervous system are exaggerated by their moral and physical 
training and education. Such is the report made by those who 
have collected statistics on these subjects — for which I shall refer 
you to the authorities, among whom no one appears to have taken 
greater pains to collect numerous statistical returns than M. Bri- 



376 THE MENSTRUA. 

erre de Boismont, in his Treatise on Menstruation. For my 
present purpose it suffices to say, that in our country girls become 
regular between fourteen and fifteen years of age. Nevertheless, 
many do not see until advanced in their sixteenth year, while a 
great number are changed at thirteen and a half, at thirteen, and 
even before they have completed their thirteenth year. I have 
known a great number of such, but I always learn it with regret. 
I say with regret, for I am assured that if the pelvis of a girl, 
who had become regular at thirteen, should be long macerated or 
subjected to ebullition in water, the several portions of her ossa 
coxalia would separate into ilium, ischium and pubis, and the 
epiphyses and apophyses would also be found unconfirmed in 
their union. Here then is a proof of want of conformableness 
in the development of the machine — for to menstruate is to be fit 
for conception, gestation and labor; but to have unconfirmed 
union of the pelvic pieces is to be unfit for those offices. But 
all want of conformableness in development is disorder, not health. 
This is the argument that ought to be regarded as unanswerable 
against early marriages, which are sacrifices ; nothing less. 

The menstrua, the catamenia, menses, courses, terms, periods, 
monthlies, monthly periods, purifications, and other names, con- 
sist of the periodical discharge of blood mixed with mucus and 
epithelium. In women in good health they return once in twenty- 
eight days, and continue during three, five or seven days, less or 
more, according to the particular constitution of the woman, and 
she eliminates an amount that greatly varies in different women, 
and even in the same individual at different times and ages. 

These monthly discharges return with great regularity from the 
fifteenth to the forty-fifth year, except when interrupted by preg- 
nancy or by giving suck. At the age of forty-five they cease to 
return, and thenceforth the female is no more capable of con- 
ceiving, as she was equally incapable previously to its first erup- 
tion. It has, therefore, a clear connection with the power of re- 
production. 

For more than twenty centuries there has been a constant 
inquiry among the learned, as to what should be the cause of a 
regular menstruation in women; a phenomenon that is common 
to them in all nations, climates and ages of the world. It is not 
wonderful that an anxious curiosity should have existed on this 
subject, seeing that the regular and healthy performance of the 



THE MENSTRUA. 377 

office is related to the health, beauty, perfection and security of 
the female, and this among all people of every age of the world. 
Nor should we be surprised to learn that many superstitious 
opinions, rules and observances in relation to it, have existed in 
ancient times, and yet linger among the better educated classes of 
society. Notwithstanding this great anxiety to learn the truth as 
to menstruation, and in despite of the researches, observations 
and conjectures of so many enlightened philosophers and physi- 
cians, no certain or even probable conclusion was reached until 
very lately, that several illustrious medical men in Europe have 
had the happiness, through a succession of fortunate discove- 
ries, all tending to the ultimate conclusion, to place the matter 
in what seems to be a clear and perfect light. So that I am of 
opinion, that ere long there will be no difference of sentiment as to 
the causes and nature of this function. I believe that they have 
arrived at the truth of this doctrine. Truth is always precious, 
and never more so than when its rays, like a bright sunbeam fall- 
ing into a darkened chamber, make manifest an object never 
clearly seen or understood before. The discovery of the truth 
upon this important subject, makes many things plain to physi- 
cians, as to counsel and action, that were obscure and uncertain 
before ; whence they are now enabled to do much good they 
could not previously effect, and avoid much evil, which their 
ignorance of the real nature of the catamenia led them unavoid- 
ably to commit. The discovery in question should, therefore, be 
hailed as one of signal importance in the practice of our art, and 
it is proper that I should devote some portion of this letter to the 
object of explaining it to you, adding such reflections of my own 
as may arise in my mind in the course of writing this letter to you. 
Before I come properly to the particular subject, I ought to pre- 
mise that great confusion and error have existed in the opinions 
heretofore formed concerning the wonderful periodicity and regu- 
larity of the catamenia, and the wonder has been the greater, 
because the intervals between the returns are so long. In very 
regular women it returns on a day that they can count upon for 
months before hand. To take a single example. January 3d, 
1843. — Mrs. told me this evening, that she became regu- 
lar at thirteen years of age. During her whole menstrual life, 
now probably closed, she was six days unwell, and her returns 
were always on the twenty-eighth day from the day of the last 



378 • THE MENSTRUA. 

attack. The returns never had reference to the phase of the moon, 
or the day of the month, nor had she ever any diseased or painful 
sensation relative to her menstrua. She had four children. 

There are many women who menstruate earlier than the twenty- 
eighth day, while others experience the returns only every thirtieth 
or thirty-fifth day, or after a still longer interval. 

The recurrence once in twenty-eight days, or once in each 
lunar month, led to the general conviction that a lunar influence 
rules the return. This notion has been for ages deeply impressed 
in the public mind ; notwithstanding millions of persons could 
daily testify to the contrary, seeing that everywhere in the same 
meridian, women are unaffected by any such influence, for there 
is probably not a moment of any day in which some women are not 
in the beginning, middle, or end of the term. If the influence of 
the moon could be justly supposed to have anything to do with it, 
it ought to be felt by the mass of the female population on the 
meridian and not upon one of a hundred. 

Another hypothesis is, that the courses are caused by a state of 
general plethora or vascular fulness, occurring regularly in the 
female, and rendered necessary to her as a reproductive or child- 
bearing creature. Her liability to pregnancy, it was thought, re- 
quired that she should habitually produce an excess of blood, so 
that, when a surplus beyond the requirements of her own consti- 
tution should be demanded by the growing embryo, that surplus 
might be at hand. But such a plethora would be inconvenient, 
unless it was reduced by menstruation, or gestation, or lactation; 
hence out of the necessity of the case she menstruates. 

To say, however, that the woman menstruates from a necessity 
to eliminate a certain quantity of blood, once a month, is merely 
to present the proposition in another form ; it is equivalent to 
saying that she menstruates because she menstruates. 

The fact is that all sorts of women are regular, whether ple- 
thoric or not. There are even some of them who menstruate, 
though quite ansemical, or to a certain extent bloodless. 

You do not prevent a female from havingher returns next Monday 
because you take fifteen ounces of blood from her arm to-day, Satur- 
day, but you certainly do remove her hyperemia by so doing. 
I have bled many women just before the return of the courses, 
without checking or at all hindering their regularity. The phy- 
siological laws of menstruation are not to be broken or prevented 



THE MENSTRUA. 379 

by any act of reducing the mass of the woman's blood. Besides, 
there are many thin, scrawney women, who lose much greater 
quantities at the time of being unwell, than the robust, and fat, 
and florid people whom you would suppose to yield a vast quantity. 
There are even women, while laboring under severe chronical 
disorders, such as shall at last bring them to the grave, who 
nevertheless menstruate quite regularly and plentifully, until a 
late period of their decline. I say this of some women, not of 
the generality, for so delicate are the machinery and working of 
this catamenial office, that, in multitudes of the sex, the slightest 
thing that can touch the health to disturb it, puts to instant 
flight all this power of life. 

Do you imagine then that a state of general plethora can be 
assumed as the cause of menstruation ? I should think not. 

The next idea was, that a local plethora, or turgescence of the 
vascular apparatus of the reproductive organs, is the cause of the 
menstrua; and that some unknown necessity, some unknown 
force caused this local plethora to rise to such a height, as to pro- 
duce the outward sign of the menstrual act, in the visible flow of 
blood from the genitalia. 

Now, this is a true doctrine, as far as it states the fact, viz., 
that a local plethora, or hyperaemia occurring at stated periods, is 
the cause of the mensual hemorrhage; but what is this unknown 
force? what this power that recuperates itself for every lunar 
period ? The solution of this question, is the solution of the long 
difficulty, and I shall proceed to lay it before you, with certain 
premises, however, because I wish to instruct you, not to dogma- 
tize with you. If I should say in a few words, that the local 
plethora is the result of the physiological function of ovulation 
which is a vital paroxysm, common to all reproducing creatures, 
whether animal or vegetable, I should merely dogmatize for you ; 
if I can lay before you the arguments by which I have been con- 
vinced, I shall be more likely to lead you to the conviction of 
what I deem a most essential truth. 

If you should pick up a pebble on the shore, or a handful of 
sand ; if you should break off a bit of stone from one of the great 
rocky strata of the earth ; or if you take in your hand some salt, 
or a piece of glass, or a bar of iron, or ingot of silver or gold, and 
carefully examine them, and inquire into the laws of their pro- 
duction and continuance in a present condition, it will be easy to 



380 THE MENSTRUA. 

arrive at the conviction that they are destitute of life, of sensibility, 
or appetency, and incapable of producing or generating their like, 
and altogether without organization, and that they are, in short, 
inorganic bodies, controlled only by the laws of the cohesive, elec- 
tive, and gravitating attractions. If now you take into your hand 
a butterfly, or the smallest creeping thing, or infusorial creature, 
or any plant, blossom, or seed, or whatsoever thing that is en- 
dowed with life — with life-force, you will perceive at once the 
difference between it and the inorganic masses, that possess only 
the brute force of matter; but if you attempt to set down in plain 
words the differences betwixt inorganic and living organic mat- 
ters, you will be surprised to find how difficult is the task. In- 
deed, it is in some instances impossible for the naturalist to decide 
at what point in a series, the organic ceases, and the inorganic 
nature begins ; and there are certain bodies, whose place has not 
as yet been ascertained, as whether belonging to the mineral, or 
to the vegetable kingdom. 

Burdach, at p. 128, vol. 4th of the Physiology, says, " when a 
mass which is homogeneous as to its substance, develops antago- 
nistic forces throughout its extent, and flows, and becomes fixed 
in certain determinate directions, the result of such motion is 
crystallization, or the acquisition of a regular form, which is de- 
termined by the nature of the mixture, and accomplished by means 
of the proper motions. The crystal is, therefore, the permanent 
expression of the moving forces ; in it, motion has become rest 
and permanent extension : activity is metamorphosed into a cor- 
responding existence ; it is extinguished as motion, and is now 
only manifested as cohesion," &c. 

Neither Mr. Burdach's views, as above set forth, nor the opin- 
ion that organic matter is characterized by the binary combina- 
tion of its elements, while a ternary, or quaternary combination 
produces animal or organic matter, can be considered as remov- 
ing the difficulty in deciding where, in matter, organic and inor- 
ganic nature are to be trenchantly divided ; but we are left to the 
conclusion that there is not actually a hiatus, or a limitrophic dis- 
tinction, but rather that they mutually pass into each other upon the 
confines of both. The philosophic poet Lucretius stumbled over 
the same difficulty that lies in our way at the present moment. 

Ignoratur enira quae sit natura anima'i, 
Nata sit, an contra nascentibus insinuetur. 



THE MENSTRUA. 381 

It appears to me that the reproductive force is the eminently 
discriminating and characterizing force as betwixt the organic 
and the inorganic bodies, since it is clear that the ponderable 
bodies, as the metals, alkalies, earths, and gases, are incapable of 
reproduction, whereas all living, or organized bodies, are but the 
repetitions, or reproductions, of forms and forces with which their 
archetypes were endowed, from the commencement of the present 
cosmic order and arrangement. 

Mr. Burdach's extract above given, would seem to warrant the 
opinion that there is this difference: viz., that in the inorganic 
bodies, the cessation of molecular motions gives them permanency 
and stability, cotemporary with the globe ; while in the organic 
matters, the cessation of motions is the signal for the final dissi- 
pation of their elementary materials. The one being permanent 
as the world, and the other unstable, transitory, vanishing like 
the morning dew, perishable as the new-mown grass, or like the 
flower that comes up, and is cut down. 

You ought, however, to remark that the Divine Author of the 
w T orld has so ordered his laws, that the fleeting and evanescent 
form of living beings, is, after all, as permanent as creation 
itself, and that while we are in our own persons such perishing 
creatures, we are permanent, I had almost said immortal, as a 
genus, or a kind ; who have been present here since the begin- 
ning, and destined to exist as long as the inorganic materials 
upon which we tread. Does it not seem, then, that God has im- 
pressed upon our natures a great Force, a great principle of ex- 
tension in time, and in space, and which insures our permanency? 
Judge, then, what must be the amazing power and necessity of 
that law, or that Force upon which the conservation here, and the 
permanency of the genus depend, and alone depend ! 

But if the Creator has fenced his genera about with such strong 
bonds as these, then it cannot be but that those bonds and laws 
are worthy of the close contemplation of the medical student, 
since all the deviations, whether as exaggerated in intensity, or 
whether as feeble and imperfect in action, must exert a potent in- 
fluence on the health and security of the individual. But if the 
physician should be able to know and understand these laws, he 
would be better prepared to provide the remedies for all the results 
of this disordered or interrupted action. 

Take further into consideration the thought, that if these laws 



382 THE MENSTRUA. 

are really so potent as to keep us forever here upon the earth as 
mankind, so that the earth cannot become again a wilderness, the 
abode only of inferior creatures, must it not be that similar laws 
and sanctions are provided for the conservation of all other forms 
of existence ? Do you not, therefore, perceive that each blade of 
glass, each tender blossom, or branching oak, or lofty pine, or 
trailing vine, repeats itself by means of the same Force, from age 
to age, so that the modest violet peeping with its blue petals and 
yellow anthers from its shelter of dewy leaves, is in fact as dura- 
ble as time itself, and that its perpetuity is secured by the same 
force that perpetuates us and all creatures besides. Every grain 
of wheat, every kernel, every seed contains a germ, every egg of 
the smallest aphis, the tiniest sparrow, the tallest ostrich, has a 
germ within it. All the spawn of fishes contains in each granule 
a germ. If you put a quart of distilled water in an open vessel 
upon your window-sill, it will soon be teeming with living infu- 
sorials, whose invisible germs float on every breeze through the 
air, and when deposited in the vase evolve themselves and be- 
come instinct with life and motion. All the mammalia are' like- 
wise reproduced from germs contained within true vitellary bodies 
or eggs. The egg of a barn-door fowl is not more perfectly an 
egg than is the microscopic egglet you find in the Graafian follicle 
of a cow, a mare, a sheep, a dog, or a whale. Each egg contains 
not only its germ, but its yolk. The viviparous creatures require 
but a small quantity of yolk about the germ, as the embryo at- 
taches itself to the living solid of the mother, the oviparous crea- 
tures require a large amount of vitellary matter, for the embryo- 
trophic wants of the germ are great, and the amount of yolk is 
conformable to the wants of the embryo. The germ in the egg 
of a humming bird is as large probably, as that in a cassowary's 
egg, but the humming bird at leaving its shell is incomparably 
smaller than the young of the cassowary or ostrich. Hence the 
embryotrophic wants of the latter are supplied by a vast quantity 
of materials, and the former by a few grains only of the same 
sort of reproductive matter. 

The germ of a whale of eighty feet in length is not larger, 
probably, than that of a perch. But the placental life of the 
balaena enables it to evolve its young of the length of twenty feet 
or more, while the spawn of the perch or salmon is not larger than 
the head of a pin, and its embryo of a conformable magnitude. 



THE MENSTRUA. 383 

I have now to ask you to inquire whether these ova, in all the 
living tribes, whether of an animal or vegetable kind, are produced 
continuously, or at stated times. But why should I ask you to 
make this inquiry, since I know that you have already made it, 
and are well informed upon the point. 

You know when you go into the gardens, in the early spring, 
to soften the soil and prepare it for planting. You know when the 
farmer mows, and when he reaps his harvest. You know when the 
lambs of the flock are yeaned, when the roses and tulips, when the 
migratory birds and fishes produce their young. How often does 
the germ production take place ? Once a year. The flight of 
the pigeon, the migration of the swallow, the annual arrival on 
our coasts of the shad, the herring, and the salmon, and cod; 
the bursting of the leaf-buds of the forest, the springing up of 
the grasses and flowers in the vernal season, are facts known to 
you, and which have taught you that germ production is not con- 
tinuous and progressive, but paroxysmal, and periodical. But, 
if throughout all nature we find that germ production is a periodi- 
cal occasion, a vital paroxysm, why do we hesitate to believe that 
we also, are under the same universal sole law of reproduction ? 
As well suppose half a dozen different principles of gravitation, or 
of cohesive, or elective attraction, as a variety of reproductive prin- 
ciples ; there is but one, which is omne vivum ex ovo, and the 
ovum is produced not continuously but paroxysm ally. 

As I am considering the subject of the periodicity of germ pro- 
duction, I shall take occasion to call your attention more particu- 
larly to a wonderful scene, that is annually presented in the United 
States. I allude to the annual rush into the American rivers of the 
different tribes of migratory fishes that force their way from the 
ocean into the mouths of our rivers, and ascending as near as they 
may towards the head waters, find at length the suitable places 
for depositing their spawn, or in plain English for laying their 
eggs, each one of which contains a germ. The fishermen of the 
Potomac and of the rivers in North Carolina, not unfrequentlv 
catch at a single haul as many as fifty thousand herrings, while 
vast quantities of shad are also captured in all the rivers of the 
Atlantic American coast. In the spawning season the salmon in 
the Oregon rivers, are so abundant, as actually to check in a de- 
gree the current of the streams, as we learn from the traveler 
Mackenzie, as well as from Messrs. Lewis and Clark. The an- 






384 THE MENSTRUA. 

nual visitation of the shad takes place in the United States in the 
spring of the year. They, perhaps, come up from the antarctic 
ice and strike our coast north of Carnaveral, entering first the 
rivers of Georgia, where they are seen sometimes about the 20th 
of January. They next and in succession explore the waters of 
the Carolinas, Virginia, Maryland, and Delaware, entering the 
streams of Pennsylvania, New Jersey, and New York, and so on 
at later and still later times of arriving until the migration is over; 
millions are consumed as fresh food and an immense number put 
up as salt fish for later consumption and for exportation. It is 
rare to find one of them in the waters that run into the Gulf of 
Mexico. Thousands of millions of herrings annually pursue the 
same course. The herring are said to come from the shores 
of Spitzbergen and the Greenland ice. They divide into two 
immense streams, one of which proceeds downwards near the 
coasts of Europe, and the other by way of Labrador, and so south, 
until their instinct teaches them the time is at hand for securing 
the reproductive product. Now this vast migration through 
many hundred leagues of trackless ocean, is compelled by an in- 
stinctive Force, which is a part of, or at least attached to the re- 
productive Force, just as the commencement of the nest for the 
mocking bird, or the darkening of the aureole for the impregnated 
woman is a part of that force. That instinctive force it is which 
causes them to ascend to the shallows where the sun's vivifying 
light and where the lessened temperature of the waters, at the 
proper season, may perfect the evolution and exclusion of the 
embryo fishes. 

In all the bony fishes, the male is destitute of any copulative 
apparatus ; and hence his only function is to follow the female, in 
order to shed his fecundating secretion over the places where her 
germs are deposited, and his voyage of hundreds of leagues, is a 
compulsory one, under the stimulation of that great reproductive 
Life-Force. Once a year he returns from his distant feeding- 
ground "in number numberless," to perform this great act for the 
conservation of the genus. It is in a staccato, not a sostenuto 
mode that this great hymn of nature is performed. Could I pos- 
sibly cite a stronger case to show the periodical, paroxysmal, puls- 
atory nature of the great reproductive function? 

In like manner, the herds of the Buffalo, on the great western 
prairies, 10,000 in a herd, wander from the Internal Provinces, to 



PERIODICITY OF OVULATION. 



385 



the banks of the Saskatchawan, annually repeating the same 
scene, and so it is with the moose, the elk, the deer, bear, wolf, 
fox, and martin ; it is so with the saurians, the chelonians, the 
ophidians; with every animal, and every vegetable; why should 
it not be thus with the woman ? It is thus. Her term is mensual, 
not annual ; she has the reproductive paroxysm every 28th day. 
Some of the domestic animals have it every 45th day; and the 
vibration is longer or shorter, according to the nature and con- 
dition of the subject of it. 

A healthy woman matures, and deposits an ovum every 28th 
day, from the age of 15 to that of 45 years, failing only in case 
of pregnancy and lactation, and sometimes not even then. She 
sometimes suffers an arrest of the force during lactation, yet in the 
majority even that arrest is but of short duration, and in many it 
does not take place at all. The closing stage of the process of 
maturing and depositing, or discharging the ovum, is attended 
with a discharge of bloody fluid from the genitalia, which is called 
menstruation, because it takes place once a month. 

Such is the opinion I entertain ; such is the opinion I desire 
that you should hold. It is founded on evidence too strong to be 
resisted, for the gentlemen who have been concerned in establish- 
ing it, have left no peg to hang a doubt upon, so thorough and 
so diligent has been the care to fence it about by both reasoning 
and facts. C. D. M. 






LETTER XXIX 



Gentlemen: — I hope you are not already fatigued with the 
discursive method in which I have spoken of the periodicity of 
germ production and deposit, throughout the two kingdoms of 
nature, vegetable and animal. I deemed it necessary to speak so, 
since this very periodicity has for 2500 years been a stumbling- 
block to the seekers in this path of inquiry; and since, if it be 
truly observable in all creatures besides, it ought to be considered 
as established for our race, as well as for them. I shall now pro- 
25 



386 PERIODICITY OF OVULATION. 

ceed to state that, in the economy of the human female, as in all 
the other creatures, there is provided an organ for the evolution of 
germs, and that these germs cannot be produced by means of any 
other of the tissues or organs, of which any animal or vegetable 
consists. This organ is the ovary. In the woman there are two 
ovaries, oval-compressed bodies, each about an inch in length, by 
half an inch in depth, and a third of an inch in thickness. But 
the size of the ovary differs in different women, being in some 
larger, and in others smaller than the above-mentioned average. 
Each ovary is attached to an angle of the womb, by means of the 
ligament of the ovary, which is a cylindrical cord, about an inch 
and a half in length, more or less, and as large as a small quill. 
Each ovary lies behind the Fallopian tube and round ligament, 
and is inclosed within the peritoneal or broad ligament, which 
gives it its covering, or indusium. Inside of this indusium, or 
peritoneal covering, is found the fibrous strong coat, or delimi- 
tary membrane of the ovary, which being taken off, nothing is 
left save the stroma, or ovarian substance, containing the Graafian 
vesicles, or Graafian follicles, or Graafian cells, as they are indis- 
criminately called. 

The stroma of the ovary is produced by the ovaric artery and 
nerve. I say produced by them, for it was originally evolved by 
them, and is constantly fed and maintained in its rate of size, 
weight, and functional power by them, as the source whence are 
derived all the accretions required by the momentary waste, 
detritus, or life-combustion of its molecules. What a curious 
speculation it is, that this long, wandering ovaric artery, and sper- 
matic nerve, should be the only artery, and only nerve in the whole 
economy capable of producing vitellus or yelk matter; for after 
all that can be said, they do produce it, and they alone. 

Nullam rem e nihilo gigni divinitus unquam, is a dogma much 
older than Lucretius. The ovary being endowed with the power 
of producing vitellus, as in the ostrich, where a vast quantity is 
evolved, and in the female of our race, where the quantity is so 
small, that a good doublet is necessary to find, and a good micro- 
scope to observe it afterwards, it is also endowed with the power of 
producing germs, of which vitellus or yelk is the sustaining prin- 
ciple, or aliment, or cytoblastema. For, even if the true germ be 
indeed Rudolph Wagner's germinal spot, (macula germinativa,) 
and is to be regarded as the nucleole of the cell, while the germinal 



PERIODICITY OF OVULATION. 387 

vesicle is the nucleus, and the vitellary membrane of the yelk the 
cell itself, still it holds good that the whole product, macula, vesicle, 
and vitellus, are products of the ovarian stroma, and that nothing 
of the nature of an animal concrete, save the stroma, could pro- 
duce it. Hence the stroma is truly the germiferous or germipa- 
rous organ; and hence, also, the dogma that I deem true, stroma 
is the sexual tissue, nay it is sex, as I said in one of my former 
letters. 

The origin of germs is a subject that might well fill the mind 
with amazement. It is so difficult to come at, that the strangest 
hypotheses have been forced into the service of its explanation. 
Lucretius says, "Semper enim partus duplici de semine con- 
stat." Lib. 4th. But this epigenetic notion could not satisfy the 
demands of reason, and hence the doctrine of ova, or germs, must 
be resorted to, and the dogma of omne vivum ex ovo, must be 
brought in to take its place. 

Supposing it true, and established as truth, that all life pro- 
ceeds from germs, or ova, still the aching void of an unsatisfied rea- 
son remained unfilled. Wherefore, it was averred that all germs, 
or ova, were originally created — each thing living at this hour, 
having proceeded from a germ which was included within the germ 
of its antecedent, back to the original creation ; so that the ova in 
the ovary of Eve contained the ova or germs of the whole human 
race down to the present day, as well as all that shall hereafter 
exist, and so of all descent, or generation. This evolution doc- 
trine was opposed by the Pythagorean idea of a palingenesis, or 
metempsychosis, under which notion you are to suppose that the 
animating principle that has heretofore animated the bodies of the 
living, seeks a new union with organizable matter, upon the dis- 
solution of its last tabernacle, and carries on the new evolution 
until again displaced, and set free to make new combinations. 

M. Huschke, by way of satisfying the insatiable hunger and thirst 
after knowledge on this point, proposes what seems a very inge- 
nious opinion. It is extremely difficult, certainly, to conceive how 
the plastic and metabolic forces of the cell, or the nucleus, or 
germ, could first be imparted to the germinal spot, (macula 
germinativa.) To do so, the mind must accept the idea of a 
new creative force, a force to create the germ, and launch it on 
its career of development and power. Such a metaphysical 



388 PERIODICITY OF OVULATION. 

stumbling-block is always in the way here. We have little diffi- 
culty in accepting the doctrine of reproduction by gemmation, 
and by scission, for we can readily follow out Trembley's experi- 
ments on the fresh water hydra, or polype, and comprehend to the 
full satisfaction of the reason and judgment, how a hydra can be 
reproduced by scission, by gemmation, or by evolution; at least 
there is a much smaller caret, or hiatus in the facts and the ration- 
ale. Now, M. Huschke supposes what I do not know that he has 
a histological right to suppose, videlicet, that the ovarian stroma 
contains, and essentially consists of acini, and that an acinus 
being, by a physiological process, cast out of its gangue in the 
ovary, carries away with it the plastic and metabolic forces that 
enable it to become a new ovule; just as a bud from a plum, 
or cherry tree, may carry away with it to another tree on which 
it is engrafted, all the peculiar forces that enable it to bear plums 
or cherries, on a new and different stock. 

By this method of M. Huschke's, you see, we are absolved 
from the whole difficulty of the discussion, for under such a view 
of the case, there is no necessity to imagine a new creation, an 
epigenesis or a palingenesis, but we have a series of successive 
evolutions, or rather extensions, or propagations, or productions 
of living matter, extending downwards in time from the acinus in 
the ovary of our common mother Eve, to that which exists in 
every female now living, or that shall hereafter live on the globe. 
Under this view, farther, we might conceive that Eve is not yet 
dead, but that by her acini she still lives by extension, after having 
evolved, in the six thousand years, all the bodies of her descendants. 

Such is the inference from the theory that the stroma is acini- 
ferous. I do not know that it is aciniferous. I have many times 
observed, in the microscope, the myriads of granular bodies 
which both Martin Barry and Gerber describe as visible in a par- 
ticle of stroma. Still I do not know whether those puncta'be 
really acini or not — if they be not acini, of course M. Huschke's 
theory falls to the ground. Certainly, however, it is a very pleas- 
ant hypothesis, since it saves us from the rude difficulty of imag- 
ining a germ created by common physiological law and without 
miracle. If you should plant a Lombardy poplar, or vine, or 
willow, your son who should plant a slip cut from it might pro- 
pagate his vine, and so on with his son, and to the millionth 
generation of your children. It is no wonder to see the cuttings 



PERIODICITY OF OVULATION. 389 

grow, but to make a creature, de novo, that is the hardest thing in 
reason or philosophy. Hence M. Huschke's hypothesis is a very 
agreeable one. I have thought it proper to lay the doctrine before 
you, and shall leave you to your own reflections upon it, begging 
you to arrive at your own conclusions. 

At different times I have exhibited to you, and great numbers 
of the class have come down into the rotunda to look at it, the 
yelk taken from the ovary of the cow, as well as that from the 
ewe. You remember that the ovarian vesicle was punctured 
with a lancet, and the drop of liquid which spirted from the in- 
cision being collected on a lamina of glass and placed under the 
microscope, the yelk containing its germinal vesicle and macula 
were shown you in one of Chevalier's microscopes. This yelk 
ball was contained within Graaff's vesicle. GraafPs vesicle has 
two coats, an inner one, and an outer one which contains the 
inner one, sphere within sphere ; but the spheres are buried be- 
neath the fibrous coat or albuginea of the ovary. The albuginea 
is contained beneath the indusium or the peritoneal coat. 

This statement, taken in connection with the fact, that the ova 
of birds and fishes, and frogs, &c, are discharged without the 
intervention of the male, or any antecedent sexual conflict, ought 
to convince any one that the fecundation of the ova does not take 
place within, but outside of the ovaria, and, therefore, the ova 
must escape from the ovaria previous to the impregnating act. 
In other words, there is a physiological function of the ovary to 
mature and discharge its ova, in order that they may be after- 
wards haply fecundated. If you admit that this statement is a 
correct one, then you accept the doctrine of the spontaneous ex- 
pulsion of ova, or the ovi-posit. Admitting the ovi-posit as a law 
of the reproductive force, then the question arises again, is this an 
irregular or a regular and periodical function? I have shown 
that throughout all living nature it is periodical, not continual, 
not irregular, not accidental. I see no bar to the conclusion that 
it is so in women. 

M. Negrier, of Angers, M. Gendrin, Dr. Robert Lee, M. Bis- 
choff, and more than everybody else, Dr. Pouchet, of Rouen, have 
taken pains to observe the state of the ovaria in women who have 
died during or soon after the act of menstruation. They have all 
found that at that crisis the ovary exhibits a mark on its surface, 
a bloody spot, a hole, a pore — into which can be pressed the 



390 PERIODICITY OF OVULATION. 

point of a probe. This hole, this pore, leads to an expanded 
crypt, filled with a minute clot of blood ; if the ovary be split 
with a scalpel conducting the incision so as to cut through the 
pore, it will be found to lay open a Graafian follicle, from which 
the egg has escaped through its pore-like hila, as happens in the 
ovary of the bird. These appearances are seen whenever an ovary 
is examined during or shortly after a menstruation. You may 
remember that I showed you such an one in the ovary of a young 
woman who died shortly after her menstrua, and what is more, I 
showed you the trace or cicatrix of the menses that preceded the 
last one, and I laid it open and showed you its crypt not yet 
closed up wuthin, though healed on the surface, and a specimen 
is now in the museum, wilich contains the uterus of a young 
person who died suddenly wdiile the menstrua were present: the 
uterus still contained the fluid, and the pore was bloody. My 
own opinion is, that you will never examine the internal genitalia 
under such circumstances without finding the fresh spot, and that 
you will not find it under any other circumstances. All this has 
been so clearly made out by M. Negrier, and particularly by M. 
Pouchet, that it is a loss of time to talk about it by w T ay of proof 
or corroboration ; and I really suppose that he w T ho does not see 
and admit the doctrine of a spontaneous ovi-posit coincident with 
menstruation, must close his eyes to the light, and deny the most 
irrefragable demonstration. 

M. Pouchet has recently, 1847, put forth an enlarged edition 
of his treatise, under the title of Theorie Positive de Vovulation 
spontanee, et de la Fecondation des Mammiferes et de Pespece hu- 
miine, haste sur V observation de toute la serie animale. This 
superb w T ork is accompanied wuth an atlas, in quarto, containing 
twenty most exquisite engravings, colored after nature, and exhi- 
biting the appearances in the most faithful manner. The plates 
are twenty in number, with many drawings on each one. M. 
Pouchet shows in Plate XII. and Plate XIII., the microscopic 
appearances of the vaginal discharges in the menstrual and inter- 
menstrual periods of the female ; discharges that consist of blood- 
discs, mucus and epithelium. Plates XIV. and XV. exhibit the 
menstrua of the sow, and the rabbit, showing that the sow and 
the rabbit, at the time of their erotic excitement, winch is regu- 
larly periodical, also discharge a fluid consisting of mucus, blood- 
corpuscles, and pavimented epithelium. I regret much that it is 



PERIODICITY OF OVULATION. 391 

not in my power to furnish you in this letter, with a faithful copy 
of these beautiful engravings, and still more, that the whole phi- 
losophical and admirable treatise is not in the hands of each one 
of you. 

M. Pouchet assures us, at p. 262 of his fine work, that the 
sow, during its menstruation, " exhibits in the vagina, a rose tint, 
and a small quantity of mucus; the microscope shows that this 
discharge is composed of fragments of epithelium, whether pavi- 
mented or cylindrical, globules of mucus, and also a very small 
proportion of blood-corpuscles." His figures representing these 
appearances in the rabbit and the sow, do not differ from those 
representing the catamenial discharges in the human female, ex- 
cept in the proportion of the blood discs, which in the latter are 
vastly more abundant. He declares that the womb before the 
bifurcation is highly red and injected, as well as the cornua. M. 
Pouchet has observed similar appearances, at the period of the ovi- 
posit, in many other mammals. He insists that, as it is more 
than sufficiently proved that the period of ovulation in the mam- 
mifers coincides with that of the periodical excitement, it is 
equally evident that similar phenomena rule the physiology of the 
female at the ovi-posit in the human being, p. 267. 

I deem it scarcely necessary to do more than refer to the ob- 
servations of Dr. Robert Lee, of London, M. Gendrin and M. 
Negrier and M. Raciborski, in France, on the subject of a spon- 
taneous ovulation and deposit in the human female. All these 
writers, however valuable their contributions on this point of 
human physiology, have but sketched and hinted at the subject, in 
comparison with the laborious researches and fine suite of rea- 
sonings of M. Pouchet as to this great physiological act. It is to 
him that we are most deeply indebted for clear views; yet the 
name of M. Negrier, of Angers, is also to be held up and honored 
by all physicians for his most valuable work, which, though it be 
less full and complete than M. Pouchet's, yet is highly meritorious, 
since it is to him we owe much of the early light thrown upon 
our path. 

I conceive that enough has been said to convince you that the 
ovulation and spontaneous deposit of ova is completely independ- 
ent of the sexual congress; and you ought to add, completely 
independent of, and disconnected with any sexual sense or senti- 
ment, in the human being, though it is far otherwise in the lower 



392 PERIODICITY OF OVULATION. 

mammals, &c. The reason of this difference is to be found in 
the high morals of reasoning creatures, as distinct from those 
beings that are governed by instinctive sense, and not by reason. 

If you accept the doctrine of the spontaneous periodical depo- 
sit of ova, then I think you have little difficulty to account for the 
mensual engorgement of the reproductive organs, or the monthly 
local plethora or turgescence or hyperemia, which is relieved so 
regularly and completely by the catamenial or mensual hemor- 
rhage. 

The evolution of a Graafian cell is more and more rapidly 
effected, as it approaches nearer and nearer to its completion. The 
largest and most mature follicle is now enveloped, so to speak, in 
a mass of injected and engorged and hypersemic tissues redolent 
with life ; it is surrounded with red vessels carrying on in it the 
development offices. The cell, like a growing tooth, is magnified 
and raised up so rapidly, that, like the gum over the tooth, the 
stroma around the cell becomes turgid, succulent — almost in- 
flamed, we might say. Under such circumstances, what wonder 
have you to find the whole ovary swollen and turgid, or the womb 
itself affected in the same way? what wonder to find the woman 
complaining of pain in the ovaric region, and in the womb — with 
aching, with heat, with sense of weight and dragging in the pel- 
vis ; and to find, on examination, that the uterus is larger, heavier, 
and more colored than in the inter- menstrual periods ? 

In fact, the womb, previous to the disengorging out-flow of the 
menstrual blood, is redder and heavier, and more succulent, than 
when it has been fully acquitted by the discharge. It is proved 
to be so upon examination in life, and the necroscopic examina- 
tion confirms it to be so; what more! It is bootless to talk about 
it any further, and I shall, therefore, desist from any further re- 
marks for the present. Farewell. C. D. M. 



THE CORPUS LUTEUM. 393 



LETTER XXX. 

Gentlemen: — I concluded my last letter with remarks on the 
periodical turgescence or hypersemia of the reproductive organs, 
caused by the rapid march of development in the last days of the 
maturation of the ovulum. 

It is quite necessary that I should, in this present communica- 
tion, explain the causes of the rise of the yelk from the centre of 
the stroma to the surface, whence it is ultimately destined to 
escape ; and in making this explanation I cannot avoid speaking 
of the corpus luteum, a yellow body which is discoverable in the 
menstruating ovary and more sensibly in the ovary of the gravid 
animal. 

I have to beg you to remember that the title of this volume, 
which treats of females, their diseases and remedies, gives me a 
very general warrant as to the choice of topics, so I but keep 
within the real boundaries of my subject ; and I believe I shall not 
go beyond those bounds if I now address you on the subject 
of the corpus luteum. I deem it, also, a matter properly related 
to the doctrines of menstruation, and one which it is requisite 
that you should take into consideration in your study of that im- 
portant physiological function. Hence, I beg you not to consider 
me as abandoning the consideration of the menstrua, while I am 
treating of the nature of the corpus luteum, my design being to 
continue my remarks on the menstrua after I shall have laid 
before you the following observations on the corpus luteum. It 
is proper to say that I lately read before the American Philoso- 
phical Society, a memoir on the subject, which the society has 
ordered for publication in their transactions. The substance of 
that memoir will be found in the present letter. 

While I was engaged last winter in my lectures at the College, 
and during my preparations for the lectures on this point, I be- 
came convinced that the views heretofore entertained as to the 
nature of the corpus luteum were unsatisfactory, at least to my 
own mind, and made some experiments which led to the inference 
that the corpus luteum is a vitellary body. 



394 THE CORPUS LUTEUM. 

Since the date of those lectures, I have carefully made researches 
both by means of the Chevallier microscope and other methods, 
as to the comparative appearances presented by fresh vitellary 
matter taken from the hen's egg and matter collected from fresh 
corpora lutea. 

These researches suffice to convince me that the yelk of eggs, 
and the yellow matter from a corpus luteum are of the same ap- 
parent constitution, form, color, odor, coagulability, refractive 
power, and microscopic appearance. 

Having placed a small quantity of yelk on the platine, I have 
been struck with the appearance of a yellow light filling the whole 
tube of the microscope, just before the object is brought into the 
focus of the instrument. 

Whenever, in like manner, I have placed a bit of fresh corpus 
luteum of the cow or sheep on the compressor, and have crushed it 
by turning the screw, I have found the tube filled with the same 
tinted light before obtaining the focus. 

A portion of yelk placed beneath the objective, and examined 
with a strong power, exhibits numerous granules, corpuscles con- 
taining a yellow fluid, oil globules, and a quantity of punctiform 
bodies, floating in a transparent liquor. 

Upon turning the screw of the compressor upon a mass of 
corpus luteum, carefully dissected out from the ovary, there is 
seen to escape from the crushed object a quantity of granules, 
corpuscles filled with yellow fluid, oil globules, and punctiform 
bodies, swimming in a pellucid liquor. 

The appearances observed upon examining a portion of yelk, 
and a portion of corpus luteum, are so similar that it would be 
difficult to discriminate between them, but for the exception that 
along with the granules and corpuscles, oil globules and puncta 
of the corpus luteum, there will be found flocks of laminated 
cellular tela, blood discs, and other detritus of the organ destroyed 
by the compressor. 

The transparent corpuscles transmit a yellow light, whether 
observed singly, or in clusters or acervuli. 

The same is true of the corpuscles of the yelk. 

Upon crushing a bit of corpus luteum in the compressor, there 
escapes much granular matter, that- accurately resembles the 
granules of the granular membrane, the retinacula, or the pro- 
ligerous disc of the Graafian follicle. This is the case where the 



THE CORPUS LUTEUM. 395 

very greatest care has been taken to procure the bit from the outer 
portion of the yellow body, so that no portion of the crypt could 
be invaded. All the portion used was from the substance of the 
corpus luteum. 

The similarity of appearance leads me to infer a similarity or 
even identity of nature and origin. I think no person, accus- 
tomed to the use of the microscope, could detect any difference 
between the molecules pressed out of the bit of corpus luteum and 
those that escape from a ruptured mammiferous ovulum (as of the 
cow or sheep), or those that are seen in common yelk of egg, ex- 
cepting the debris or detritus before mentioned, should signalize 
the difference. 

I have so many times examined the mammiferous ovulum, that 
I suppose myself to be quite competent to compare its contents 
with those of the corpus luteum, and with that of the bird's egg, 
and I feel that I am entitled to say with confidence that, the chief 
constituent bulk of a corpus luteum is a true vitellary matter, 
deposited outside of the inner concentric spherule or ovisac of 
the Graafian vesicle ; that is to say, the vitellary matter of the 
corpus luteum is deposited betwixt the inner and the outer sacculus 
of the follicle. 

As to the correctness of this opinion, I must refer to#the future 
observations of the micrographers, who will be able to confute or 
to confirm my statement and opinions. 

I do not know that any author has expressed a similar opinion 
as to the constitution of the corpus luteum, though that substance 
has been the fruitful topic of elaborate discussions, and of re- 
searches, and hypotheses, for many years among the learned, in 
consequence of the importance of the subject, both in a physiologi- 
cal relation and in a medico-legal application. 

It is surprising to observe how much has been said about it, with- 
out coming to any reasonable conclusions. You ought to know 
that previous to the year 1825, nothing was in fact clearly under- 
stood about it. But in that year, John Evangelist Purkinje, of 
Breslau, in Silesia, discovered the germinal vesicle in the unfe- 
cundated egg of the barn door fowl. In 1827, Oh. Ernest Von 
Baer detected the mammal ovulum with its germinal vesicle. In 
1830, Rudolph Wagner ascertained the macula germinativa or 
germinal spot. You may therefore safely venture to say, that 
antecedently to these epochs, viz., 1825, 1827, 1830, all talk, all 



396 THE CORPUS LUTEUM. 

discussion, and opinion on the mammal ovum was naught. Hence, 
I should think it bootless here to ask what the writers, previous to 
1825, may have said or supposed about it. 

Of those who have written concerning the corpus luteum, since 
the above dates, I have to say as to the constitution of the yellow 
body, that Drs. Carpenter, J. Miiller, Thomas Schwann, Henle, 
Huschke, have not hinted as to its vitellary nature. Dr. Henle, 
in his Algemeine Anatomie, says, "So weiss man namentlich, wie 
die Graafschen Blaschen, in Folge der Congestion, welche dem 
fruchtbaren Beischlaf folgt, zuerst anschwellen und denn platzen, 
wahrend sie zugleich von Blut angefiillt werden, welches sie 
allmahlig entfarbt, organisirt und in eine Narbensubstanz ver- 
wandelt, die zuletzt verschwindet" — p. 894. 

In the passage here quoted, Dr. Henle attributes the swelling 
and the bursting of the Graafian follicle to the congestion attend- 
ing a fecundative union of the sexes. He says the ruptured 
cell is filled with blood which colors it, becomes organized, con- 
verted into a scar-like substance (narbensubstanz) and after some 
time disappears. 

Dr. Huschke, in his Treatise on Splanchnology, elaborately 
details the opinions of authors on the corpus luteum, but nowhere 
alludes to*the vitellary nature of that substance. 

Messrs. Gendrin, Negrier, Robert Lee, Wharton Jones, Raci- 
borski, Ollivier d'Angers, and Pouchet, make no such allusion; 
they all enter into details. 

Dr. Montgomery, Dr. Swan, M. Flourens, MM. Velpeau, Mo- 
reau, Jacquemier, Cazeaux, and Chailly are silent as to the vitel- 
lary constitution of the yellow body. 

Bernhardt, who was assisted in the preparation of his Symbolce 
ad ovi Mammalium Historiam ante Prcegnationem, by Dr. Valen- 
tin, and in which admired work you may find a complete deduc- 
tion of the whole literature of the corpus luteum, alludes not to 
its vitellary nature. 

The celebrated letter of Professor Von Baer, de Ovi Mammalium 
et Hominis Genesi, says of the corpus luteum, at page 20, "Me 
judice minime corpus novum est, sed stratum internum thecae 
majus evolutum," which sets forth with sufficient clearness and 
great conciseness the opinions entertained in the rest of the para- 
graph. 

Dr. Bischoff, of Heidelberg formerly, but now of the University 



THE CORPUS LUTEUM. 397 

of Giessen, in his Entwickelungsgeschichte der Sdugethiere und 
der Menschen, says, at page 33, " Wenn man die erste Entwickel- 
ung des gelben Korpers unmittelbar nach Austritt des Eies bei 
Thieren beobachtet hat, so kann man dariiber nicht in Zweifel 
sein, dass die Bildung seiner Masse von der innern Flache des 
Graafschens Blaschens ausgeht. Da sich nun hier die aus Zellen 
gebildete membrana granulosa befindet, und dieselbe als gelber 
Korper erkennbare Masse gleichfalls aus Zellen besteht, so ist es 
wohl gewiss, dass von einer starkeren Entwickelung dieser Zellen 
der membrana granulosa, die ich auch in der Peripharie des Eies 
noch nachweisen werde, die Bildung des gelben Korpers aus- 
geht." 

From the above passage, it appears that M. Bischoff was not 
far from discovering what I suppose myself to have discovered, I 
mean the vitellary nature of the corpus luteum ; since, he says 
it is composed of cells, and proceeds from the inner membrane 
of the Graafian vesicle. 

I shall make for you no further citation of authoritative opinions 
here. 

I pray you suffer me to remark, that if the inner concave super- 
ficies of the true ovisac, or inner concentric spherule, is charged 
with the function of producing or excreting the corpuscles of the 
vitellus of the ovulum, or the materials of them, which cannot be 
denied, there is no difficulty to conceive that the convex or ex- 
terior surface of the membrane may exercise the same function, 
as dominant of the elective affinities, which must be supposed 
of this as of every other vital excrete. Such a supposition is 
not a wresting of physiology, and it finds abundant support in the 
analogy of the organs, as for example in the periosteal and 
medullary membranes of bone, which, under certain circum- 
stances, are known to alternate their functional forces. The 
medullary membrane, in the cases alluded to, comes to be a de- 
positor of phosphate of lime, instead of a remover, its natural 
office ; whereas the periosteum in turn, becomes a remover instead 
of a depositor, its normal function. This mutation and interchange 
of powers as to the inner and outer membranes of bone, have been 
too clearly exhibited and demonstrated by M. Flourens, in his 
admirable paper on the reproduction of bones and teeth, to ad- 
mit of any doubt or cavil. But I am very far from claiming this 
illustration as proof in favor of my views, strong as I might deem 



398 THE CORPUS LUTEUM. 

it to be. It seems to me sufficient to know this, namely, that 
vitellary matter is germinal matter, germinal cyto-blastem, and 
that it is the office of an ovary to produce it, and that nothing 
else in nature can do so. 

It is with deference to the opinions of persons more learned 
than I, and far more versed in the use of the microscope, that I 
make public these opinions, which I am well aware cannot stand 
upon my single testimony. I therefore readily confide in the 
opinions to be hereafter formed as to these views, by the micro- 
graphers, and I doubt not MM. Pouchet, BischofT, Wharton Jones 
or others, will confirm or reject these views according to their 
own more able observations to be hereafter made. 

As to some points of resemblance not yet mentioned, I have to 
observe that boiled corpus luteum, becomes like boiled yelk of 
egg, very hard, and in like manner friable and granular; leaving 
a yellow stain upon the fingers or on white paper, when rubbed 
on them. Dr. Thomas Schwann says he found the corpus luteum 
to become hard, coagulated, granular, and friable, upon being 
boiled. 

I threw a portion of fresh corpus luteum on a live coal; it gave 
out the odor of roasted egg. 

Hence, in coagulability, in friableness, in staining yellow, in 
becoming granular, and in yielding when burned the odor of 
roasted eggs, the corpus luteum resembles vitellus, as much as it 
resembles it in its microscopic characters. 

I think that these circumstances warrant me in forming the 
opinion that the corpus luteum is a vitellary body. 

In reflecting upon this subject, the question arises, are the 
granules and corpuscles of the corpus luteum cytoblasts and 
cells ? 

I endeavored with a very high power to make out the nuclei 
of the corpuscles, but could not succeed in doing so ; nevertheless, 
I cannot suppose that the invisibility of a nucleus is to deprive a 
body of the character of the cell. Even Dr. Schwann himself, 
at page 204 of that wonderful work, the Mikroscopische Untersu- 
chungen, says, "Die kernlose Zellen, oder richtiger ausgedriickt 
die Zellen in denen bis jetzt noch keine Kerne beobachtet worden 
sind, kommen nur bei niedere Pflanzen vor, und sind auch bei 
Thieren selten;" and he cites as samples of the non-nucleated 



THE CORPUS LUTEUM. 399 

cell the young cells within the old cells of the chorda dorsalis, the 
cells of the yelk of the bird's egg, &c. 

Whether the non-nucleated vesicle be a cell or not, it is very 
certain that the milk corpuscle, and probably, the chyle corpuscle 
are of that nature, and no one can contemplate the evolution 
progress of a corpuscle or spore of saccharomyces cerevisia?, with- 
out admitting for it at all the qualities and development forces of 
the mother cell: it is to the last degree reproductive; while the 
filiform fungi, the muscardine, and many other sporiferous bodies 
claim to possess the same metabolic and formative powers. 

Supposing that my view is sound as to the vitellary nature 
of the corpus luteum, then you will observe how beautifully simple 
and concise is the machinery or apparatus by which the ovulum 
is brought to the surface and deposited ready for fecundation, on 
the ovarian indusium or within the fimbria of the Fallopian tube. 

In the bird's egg, which, as in the ostrich and the cassowa^, 
contains a gigantic yelk, the simple augmented tension of the 
membranous sacculus of the ovary suffices to open the ovisac upon 
its hila. The same happens in the immense yelk of the larger 
ophidians, as the coluber Boseformis, figured by Dr. Swan, and 
indeed in all the membranous ovaria. 

But, in the dense tissues of the mammal ovarium a special pro- 
vision for the opening of the porule or hila, for the escape of the 
ovulum, was required. 

How has it been effected? Is it not as follows? 

The function of stroma is to produce germs and vitellus. When 
the production of the germ on the inner face of the vesicle buried 
within the vitellus is complete, the ovulum is ripe; it has attained 
its generical magnitude and weight; but the stroma continues to 
supply the vitellary matter; it deposits it betwixt the two concen- 
tric spherules of the follicle. The inner spherule yields to the 
pressure of the increasing mass and becomes convoluted as it is 
crushed inwards towards the yelk ball. The outer spherule is 
driven outwards against the gangue of the ovarian stroma, and 
the deposit goes on, particularly in the cow and the swine, to a 
vast extent, making, in some instances, a mass of corpus luteum 
equal to half the volume of the ovary. 

At the same time the inner concentric, growing smaller and 
smaller from the pressure towards its centre, lifts the yolk ball to 
the albuginea and indusium where the resistance is weakest. The 



400 THE CORPUS LUTEUM. 

cavity of the follicle becomes reduced nearly to nothing, as the 
pressure augments, until at last the porule, being established by 
the absorbents or by rupture, the yolk ball escapes, along with its 
granular membrane, in fragments, leaving a crypt which becomes 
filled with coagulated blood, the crypt being contained within a 
yellow mass of vitellus called the corpus luteum, which at some 
stage, as yet unascertained, begins to be absorbed as the vitelli- 
ferous forces of the stroma become determined towards the de- 
velopment of another follicle. It would be unreasonable to sup- 
pose that upon the escape of the ovulum, the yelk-producing force 
and activity should be immediately suspended. It is even pro- 
bable that the corpus luteum may continue to augment for a certain 
but unknown short period. 

It is a periodical exacerbative or paroxysmal force, that develops 
the ovulum. It is employed first upon one and next upon another 
germ point, and so on throughout the reproductive life of the 
woman or the animal, at the pairing season of birds, the rut of the 
mammals, the reproductive periods of the reptiles, fishes, insects. 

I am surprised to find that some able and distinguished writers 
still cling to the antiquated notion of ovarian fecundation. But I 
presume that M. Pouchet's illustrated work on ovulation will put 
to flight all cavils on that point. 

No woman can menstruate but in coincidence with the sponta- 
neous ovi-posit. Every ovi-posit is followed by a corpus luteum, 
except where a failure of development may possibly, as a disease, 
prevent it. The corpora lute a are of various sizes. Many wo- 
men have scarcely discernible ones after conception. I recall to 
your memory the gravid uterus with its young seven months' foetus, 
in my collection, in which no trace of a corpus luteum is dis- 
coverable. 

The true and false corpora lutea of Dr. Montgomery are all 
equally true corpora lutea ; and though different in size, are not 
essentially different in nature. 

My letter would be far more satisfactory to me, were it in my 
power to accompany these pages with copies of M. Pouchet's ex- 
quisite colored drawings of these objects, but it is not in my power 
to do so. I warmly recommend them to your attentive and careful 
study. 

And now, gentlemen, do you ask me what is the use of all 
these remarks on the corpus luteum? I answer, that my letters 



MENSTRUA. 401 

are of females, their diseases, and remedies. You would not un- 
derstand the nature of women if you should not study their corpora 
lutea. 

In studying their nature and offices, you may find a key to 
much admirable pathology. In my own mind there has long 
existed not the least doubt as to the power of these bodies to 
develop the very beginning of lying-in diseases, and others. 

If, in a court of justice, you come to stand as a witness, subject 
to the interrogations and cross-questionings of a lawyer, you would 
be thankful for the whole history of these bodies, as given by 
Bernhardt, and, afortiori 7 you would be happy to save some person 
accused, from the gross misjudgments of lawyers, judges, and 
juries, who might condemn an innocent person, out of their igno- 
rance of the true laws of the ovulation and spontaneous ovi-posit 
in the human female. 

I therefore again recommend this point to your careful contem- 
plation, and shall now bid you farewell with the intention to re- 
sume my remarks on the menstrua, which have been, seemingly, 
not really, interrupted by the present episode on the yellow bodies 
of the ovaria. C. D. M. 



LETTER XXXI. 

Gentlemen: — My last letter, No. XXX, was occupied with 
an account I desired to lay before you of my views relative to the 
corpora lutea, one which I considered it proper to introduce into 
the series of remarks on menstruation. I know not what you or 
others may think of the idea set forth therein as to the vitellary 
nature of that body, — but, I hope that, whatever may be your 
opinion on that point, you will, at least, agree with me in con- 
sidering those bodies as a part of the normal results of the men- 
sual ovulation, for that is the main point ; and that is the point of 
interest in any medico-legal discussion or testimony you may- 
hereafter happen to be engaged in. 

Having said what I wished to say to you on the corpus luteum, 
26 



402 MENSTRUA. 

we shall now, if you please, proceed with our observations on the 
menstrua. 

From what has already been remarked, I presume you have 
perceived that, in contemplating the nature and laws of the cata- 
menia, I adopt the notion that the act of menstruation, rigorously 
construed, consists in the periodical maturation and deposit of an 
ovulum ; of which act the flowing of the menstrual blood is but 
the outward and visible sign — so that, in fact, a woman may 
menstruate very regularly and exactly, without having the least 
hemorrhagic sign of that menstruation. Doubtless many women 
are perfectly regular who give no outward sign of it. Do you 
doubt the truth of this proposition? If you do, then I ask you if 
it be not proved by the fact that a great many women who 
give suck, do not have their courses until they wean the child? 
It is true that, a great many women, during their lactation, find 
themselves to become regularly unwell from the seventh month ; 
and it is also usual to observe that a woman lying-in, has a return 
of the courses six weeks after the birth of the child. This is so 
generally the case, that I always expect my patient to be unwell 
again at the sixth week; and to be regularly menstruous from 
the seventh month. This is the rule — the exceptions are in those 
women who never see until they wean the child, of which class 
the number is large. 

April 21th, 1847.— Mrs. d told me this day that she 

never saw her menstrua while nursing, nor until three months 
after she had weaned the child. This is her fourth child; she 
is a small and very delicate person. One of her children was 
suckled for thirteen months. 

Brierre de Boismont says, at page 159, that he inquired as to 
the return of the menses in eighty-two women who had been con- 
fined. 

the menses returned immediately after the labor ! 



In 


1 the mer 


In 


1 < 


In 


2 < 


In 


4 


In 


9 < 


In 38 


In 


7 


In 


7 < 


In 


6 < 



in 


8 days! 


in 


15 " 


in 


3 weeks. 


in 


1 month. 


in 


6 weeks. 


in 


5 to 6 weeks 


in 


2 months. 


in 


3 months. 



MENSTRUA. 403 

In 2 " " in 4 months. 

In 3 " " in 5 to 6 months. 

In 2 " « in 7 to 8 months. 

M. de Boismont's statistical return ought not, I think, to influ- 
ence you in your opinion. I feel very sure that a much truer 
statistics than the above, is the one in which I told you that your 
patient may expect it to return in six weeks ; and then become re- 
gular and continue so from and after the seventh month. But sta- 
tistics often fly in the face of opinions as well as of the truth as ac- 
knowledged in the world, or by the public whom it may concern. 

You ought farther, to learn that, some women do not see from 
the time of their first conception until they have borne a con- 
siderable number of children, because, becoming fecundated 
while they are nursing, they carry out the pregnancy to term, 
become again enceinte, and so on, never seeing their courses as I 
said, until, being no longer impregnated, the ovulation is marked 
by a natural return of the mensual hemorrhage. I have met w T ith 
several samples of this kind; and they are so abundantly re- 
corded in our books that there is no need to cite the cases; you 
may set it down as a fact, that it is so, with not a few women. 
How could it be otherwise with those women who have a child 
every year, or eleven months. I have seen a child born at ten 
months after its antecedent. 

Now, supposing the ovulation and spontaneous deposit of the 
ovule to be the true doctrine, do you not see that these suckling 
women, in question, did really produce ovules for fecundation, 
though they did not have the menstrual discharge ? I deem it no 
matter of surprise that they had not the menstrual discharge, be- 
cause I can perceive in the function of lactation, an action de- 
rivative from the internal genitalia to the mammary glands, of 
strength sufficient to turn aside the determinations, whether san- 
guine or nervous, of the constitution, from the genitalia to the 
lactiferous apparatus. Many other things turn it aside in the 
same way. There are many women who may be presumed to 
have the inward menstruation, videlicet, the ovulation, without any 
bleeding ; a case that may take place without the least shock to 
the woman's health. A young woman, for example, may have 
reached the proper age for menstruation without having seen the 
sign, or show. She may be married, conceive, and bear a child 
— suckle it, and at the end of seven months have her first men- 



404 MENSTRUA. 

struation. This has been observed to happen more than once. 
Who can doubt that she matured and deposited her germs, which 
were fecundated after her marriage ? Or will you go back to the 
idols, and embrace the old doctrine that the germs were fecun- 
dated in the ovaria? If you will go back to such idols, I have 
nothing to do but "let you alone." 

You might well suppose that pregnancy will put a stop to the 
ovulation — and perhaps, in a majority of cases, it is true that 
when the womb has once fairly begun its career of gravid de- 
velopment, the sanguine and nervous forces of the reproductive 
organs are so completely absorbed in the business of gestation, 
that the ovarian function is suspended, or proceeds but slowly and 
feebly at most. Yet there are pregnant women, not a few, who 
have regular mensual returns for three or even four months. I 
had a patient here who was regularly unwell up to the eighth 
month, when I attended her. She went out her time, and was 
laid at the ninth month. 

Moreover, some women have the most insuperable tendency to 
miscarry, and those miscarriages are found to take place at the 
period of their usual menstruation — in fact, the major part of the 
abortions and threats of abortion, you are hereafter to meet with, 
coincide with the woman's catamenial period ; a fact very im- 
portant for you to know, because, you ought to take measures to 
obviate the danger at the time — and when the time is passed re- 
lieve the patient from the onus of an unnecessary treatment. 

All the foregoing may suffice to show you that you are not to 
take in hand every female who does not have the show just at the 
time it is expected, and that you will be at liberty to suppose that 
her constitution does not suffer the least injury; because, while 
she does not seem to be regular, she is, in fact, perfectly regular; 
that is to say, she regularly matures, and deposits her germs, — 
for that is the physiological act of menstruation, and nothing else 
is. That is what her constitution requires her to do. If she 
bleeds, it is well ; but she is often found to be well even if she 
does not bleed a drop. Is it not so with the suckling woman? 
I am glad to have an opportunity to tell you these things, for I 
hope they may have the effect to make you keep clear sometimes 
of the drugging process which is too apt to be set on foot the mo- 
ment a lady complains of amenorrhcea. 

In a former letter I said I had often seen young women lose 



MENSTRUA. 405 

their courses when brought to town, and set on the school-form, 
yet retaining all the outward appearances of valid health. When- 
ever I have been consulted as to such a one, I have made a very 
careful exploration of the rate and degree of the various functions ; 
and when I have found that the intellection, the respiration, circu- 
lation, innervation, calorification, digestion, secretions, &c, are 
all normal, and that nothing is wanting save the menstruous show, 
I have let the patient alone, merely directing a close surveillance 
of her health, and proposing to interfere only in case some further 
signs of disorder should present themselves. The deviation in 
such cases I have attributed to the consumption of the nerve force, 
the neurosity, by the hemispheres, in the too constant operation of 
the powers of the intelligence. A holiday, or a return to their 
homes, cures them better than drugs. Do not, I pray, let me mis- 
lead you here. On the contrary, I repeat that the state of the 
whole constitution should be carefully explored, and when thera- 
peutical treatment is evidently demanded, see to it that the true 
indications be fulfilled. 

I have now another topic to speak of, and that is a case where 
you are called to a person who complains of a retention of the 
menses, appealing to you for relief. 

The stupidest thing a physician can do, is to be misled by such 
complaints to the administering of drugs and medicines, which 
may bring on, not the menses, but an abortion, or a premature 
labor. How can a man look more like a fool than he who suffers 
himself to be entrapped to the commission of such a wrong? 

If a woman comes to your office, or if you be called to her 
dwelling to speak with her on such a subject, you may perceive 
at a glance that she is sick ; but you may as readily also discover 
by a single look that she presents all the signs of the most con- 
summate health. How can a woman exhibit all the signs of ro- 
bust health, and yet fail of her menstruation, when she has always 
before been perfectly regular, and when neither disease nor stu- 
dies, nor misfortunes can be supposed to have had power to inter- 
rupt the course of a function always sure to be exercised when 
nothing stands in the way of its exercise ? 

I am far from advising you to be constantly on the look out for 
sin, and smelling out every possible iniquity. But I do advise 
you so to demean yourselves that you shall bring no discredit on 
yourself, or on your profession. Our profession, alas ! has a vast 



406 MENSTRUA. 

weight of incompetency among its own asseclse, and an immense 
onus of charlatanry among the whole race of quacks and pre- 
tenders to bear upon its ample shoulders. You will be in the good 
path if you determine early to give no occasion for additional 
scandal by your conduct as physicians. It will be your duty, 
then, in all these cases, not to suffer yourselves to be misled and 
imposed upon. 

I was sent for to see a young woman. Upon reaching the house 

her married sister said that she wished me to visit , as 

she was quite out of health. 

"What ails her?" 

"I suppose it is her courses; she has not been right for 
several months. Go up stairs, and you will find her in the 
chamber." 

" Does she appear to be ill ?" 

"No, not at all." 

She was sitting in a chair, bending over a tambor-frame, 
where she seemed to be most diligently employed passing the 
needle in and out of the stuff at which she was working. 

I observed that she blushed as I entered the apartment, and 
seemed agitated, whether from a modest timidity, or from a con- 
sciousness of impending disclosure. Her face was radiant with 
health and bloom, and her embonpoint was visible on her shoul- 
ders and arms. 

She told me, in answer to my inquiries, that she had seen no- 
thing for near seven months, but was very much swollen — was 
fearful of a dropsy — had no pain — good appetite, sleep, digestion, 
and strength. The pulse was normal, except the slight precipi- 
tation, a pathemate mentis. She very reluctantly allowed me to 
place my hand on the abdomen, stooping the while over her tam- 
bor-frame. I held the hand there a long time, but could not dis- 
cover any spontaneous motion, nor did I hint at the object I had 
in view T — which was to discover the movement of a child. After 
some conversation, she allowed me to auscult the abdomen, 
which w r as as large, and as regularly developed as in a gestation 
of seven months ; upon adjusting the ear I heard the click of 
the infant's heart. 

When I informed her of my discovery, she most indignantly de- 
nied it, and was angry with me for the liberty I took to say, that 
she, an unmarried woman, was in the family way ; but at length 



MENSTRUA. 407 

gave in and made her arrangements for the accouchement — which 
was very happily effected at the due time. The child was taken 
kind care of, and is well. She refused to marry her seducer — 
but two years later married a worthy man, after informing him of 
her mishap. They live prosperously together, and are raising 
their hopeful children. 

I am aware it would not be well to fill up this book with cases 
of this kind, of which I have met with a great number, some of 
them very curious ones. I have only recited the above to show 

you how easy it would be to have taken 's word as to her 

case, to give her a violent emeto-cathartic, some savine, ergot, or 
what not, and bring on a premature labor at the risk of her life, 
and to the discredit of our divine art. You never will make such 
a mistake if you will make a good rule and follow it religiously. 
Let that rule be, not to speak until you know. If you will conjec- 
ture, if you will guess, let it be a conjecture, a guess, or a sur- 
mise; but when you know, then you can speak. 

I need not again advert to the case of non-appearance of the 
menses, depending upon atresia of the organs, having already 
spoken of that accident in a former letter. 

As to the quantity and duration of the mensual discharge, I have 
to say, that each woman, in good health, has a rate of her own. 
Some discharge one ounce of blood, and some twenty ounces at 
each period. The quantity a woman loses, depends upon some 
peculiarity of her constitution. In like manner the quantity a 
woman loses in her labor depends on some such peculiarity. 
Many women bring the child into the world without staining the 
napkins and cloths about them, and I have many times taken 
away the placenta without a red spot on my hands; the woman 
afterwards having only a moderate lochia, not so considerable as 
the ordinary menstrua of other women. On the other hand you 
will meet with patients who discharge a great deal of blood with 
the child, and always do so — while the post-partum discharge is 
also so considerable as invariably to reduce the strength. 

The great matter in diagnosis, then, is to learn the amount, and 
to ascertain the constitutional wants or demands and habit of the 
patient herself. 

One may be well enough able to judge of the quantity imbibed 
by a napkin; from one to two tablespoonfuls would render it 
uncomfortable. But a tablespoonful is half a fluidounce, then 



408 MENSTRUA. 

twenty-four napkins would, by estimate, be twelve fluid ounces. 
But it is often much more than that- — for on some of the napkins 
there will be found from an ounce to an ounce and a half. 

Haller, in lib. xxviii., sec. iii., says, "The quantity of blood 
discharged is various; it is greater in warm climates, being as 
much as a pound or even more — or it may be equal to ten ounces ; 
or it may go to the extent of producing deliquium animi, and 
even death itself. In cold climates the discharge may be six 
ounces, five, four, or it may be as low as three ounces," &c. 
He speaks of the effects of diet, showing that those who live 
well are more free in their menstrua than those who are com- 
pelled to subsist on spare, and poor rations. 

There is an observation as to the quantity of menstrual fluid pro- 
duced in a given time, that is unique, so far as I know: it was 
made by M. Brierre de Boismont, and is found in his work on Men- 
struation, p. 172. He says, that one of his patients had the com- 
plaisance to lend herself for the experiment, which was performed 
by adjusting a speculumto the vaginal cervix which it exactly fitted. 
The cervix remained like a plug in the speculum for ten hours. 
By this means the product was collected, and must have been 
free from any admixture with the excretions of the vagina. The 
quantity of fluid that escaped from the womb was twenty-two 
grammes, which is a little more than an ounce. At this rate 
twenty-four hours would have produced nearly two and a half 
ounces. This person had had several children. She was thirty- 
five years of age. She was of a delicate constitution — her menses 
usually lasted eight days — probably she would usually lose ten to 
twelve ounces, therefore, at each menstruation. 

When people consult me on these points, I am accustomed to in- 
quire how many changes they have been in the habit of making dur- 
ing the whole menstruation. Now, many individuals have assured 
me they always use eighteen, twenty, twenty-five, and some of 
them thirty changes, in each mensual period. Others have em- 
ployed only six — -some three, and now and then I have met 
with a person who never used any in her whole menstrual life. 
Hence, it is easy to perceive what great differences there are 
among females as to the amount eliminated. 

I am but little inclined, gentlemen, to enter upon any further 
discussion as to the nature of the menstrual fluid, as to whether 
it be a secretion from the arteries or the veins. Such discussions 



MENSTRUA. 409 

are of little profit. At least I am so fixed in the belief that I am 
correct in calling it the mensual hemorrhage, that I shall proba- 
bly never adopt any other view of it ; and it therefore appears to 
me idle to endeavor to reason one into the belief that it is a secre- 
tion — in the same sense that bile, or saliva, or milk, are secretions. 
The menstrual fluid is blood. All writers and authorities are 
not agreed upon this point. Among others I may mention that 
Mr. Hunter regarded it as differing from blood, on account of its 
not coagulating. Dr. Burns, the author of a system of Midwifery, 
was of the same opinion, as is also Professor Chapman, of the 
University of Pennsylvania, (see his note at p. 106 of James' 
Burns.) The late Professor Dewees, in his Treatise on Diseases of 
Females, at p. 87, observes, "I adopt the opinion that the men- 
strual discharge is a genuine secretion," &c. It is unnecessary 
to cite a great number of persons of the same way of thinking. I 
merely cite the above to show you that the opinion is held. 

I have had pretty numerous opportunities of inspecting the 
menstrual product, and I remain convinced that it is blood — but 
I am ready to pin my faith in this matter to the sleeve of a person 
better qualified to judge of it than you or I. I mean the late 
Madame Boivin, author of the Memorial sur VArt des Accouche- 
mens — long Sage Femme en chef of the Maison des Accouchemens 
at Paris, and author of the admirable Treatise on the Diseases of 
Women, &c. Her writings prove her to have been a most learned 
physician, and as she enjoyed a very large practice, her science 
and her great clinical experience, as well as her own personal 
knowledge, are more to be relied on than that of all the male phy- 
sicians together. She says, " The blood of the menses is just like 
that which is taken away from a vein." 

I say, I rely more upon Madame Boivin, than upon anybody 
else. I do not see what particular privilege we men have to know- 
best what the discharge consists of. I do know very well, that 
women have a sensibility, a shame-facedness about it that makes 
them very reluctant even to talk about their courses, and they are 
very far from exhibiting the material. A woman will get drunk, 
she will prostitute herself for a shilling, she will walk in the 
public streets, in rags and filth, she will curse and brawl, and be- 
come in all respects utterly, thoroughly profligate and debauched, 
but she will not show her napkin if she can avoid doing so. She 
conceals her menses from all eyes but her own, insomuch, that 



410 MENSTRUA. 

even where her moral faculty has become a hopeless, cureless 
ruin ; where decency, and the last remainder of womanly modesty 
are clean gone, she still clings to the inherent respect and shame 
that she feels on account of this strange function of her body. 
She always dislikes to talk of it, and abhors the open exhibition 
of it. It was unclean in the sight of all Israel. How then are we 
doctors to become the best judges of it ? We may practice physic 
for half a century and have a few rare occasions to inspect it, and 
those only when it is morbid. I say it again, I consider Madame 
Boivin's declaration worth more than the contrary opinion of a 
Consistory of Physicians. 

MM. Andral and Gavarret, in their frequent analyses of human 
blood, settled down to the conclusion that healthy blood, say 
1000 grains, contains of 

Water 790 grains. 

Globules 127 " 

Albumen 80 " 

Fibrin 3 " 

The analysis by Becquerel and Rodier, of blood of eleven men, 
gives the following mean result on 1000 grains — 
Water 799-0 

Solid constituents 201 '0 

Fibrin 2'2 

Fat 3-2 

Albumen 69*4 

Globules 141-1 

Extractive matter and salts 6 -8 
I have quoted the above stated analyses of blood in order that 
you may be able to compare them with the following analyses of 
the menstrual fluid. 

M. Brierre de Boismont, in his work on Menstruation, gives at 
p. 172, this analysis by Denis, of the menstrual fluid of a healthy 
woman aged twenty-seven years. It appeared to him to be a 
mixture of blood with mucus, and consisted of 

Water 825-00 

Globules 64-40 

Albumen 48-30 

Extractive matter 1*10 

Fatty " 3-90 

Saline " 12-00 

Mucus " 45-30 



MENSTRUA. 411 

The patient of B. de B., who has been already mentioned, 
agreed to allow a portion of menstrual fluid to be collected in such 
a manner as to prevent any admixture of vaginal mucus. This 
was done, as I said, by adjusting the mouth of a speculum uteri 
upon the cylinder of the cervix. The fluid passing through the 
tube was collected from the other end. It yielded to the one 
hundred parts of 

Water 90-08 

Fixed matter 6*92 

The fixed matter was composed of 

Fibrin, Albumen and coloring matter 75*27 
Extractive matter 1*42 

Fatty " 2-21 

Salts 5-31 

Mucus 10-79 

Rindskopf (vide Simon's Chemistry of Man, 337), found the 
menstrual fluid acid, and it contained 

Water 820-830 

Solid residuum 179-170 

Salts 10-150 

In a second analysis, he found 

Water 822-892 

Albumen and hsemato-globulin 156*457 

Extractive matter and salts 20-651 

Simon's Analysis. 

Water 785-000 

Solid constituents 215-000 

Fat 2-580 

Albumen 76-540 

Hsemato-globulin 120-400 

Extractive and salts 8-600 

Dr. Letheby, Lancet, May 2, 1845, analyzed menstrual fluid 

delivered from an imperforate hymen. It contained 

Water 857-4 

Solid constituents 142*6 

Fat 5*3 

Albumen 69*4 

Globules 49-1 

Hazsmatin 2*9 

Salts 8*0 

Extractive 6*7 



412 MENSTRUA. 

Now that I have laid before you these statements of analysis 
both of pure blood, and of the fluid of the catamenia, I leave you 
to judge whether the menstrual discharge is a mensual hemor- 
rhage or a menstrual secretion. I presume you will feel inclined 
to look upon it as a periodical hemorrhage, like a periodical epis- 
taxis, exhibiting modified appearances according to the quantity 
of epithelial scales and mucus that happens to be combined with 
it. For my part, I follow Madame Boivin, and I prefer her au- 
thority even to that of the chemists and micrographers. I beg 
leave to repeat that although, in the course of a long practice, a 
physician does meet with occasions, where, upon some difficult diag- 
nosis, he must ask the privilege to examine the napkin, it remains 
true that a woman in health never calls in the doctor upon that 
point at least, and that when he does find a necessity to examine 
it, there is disorder or suspicion of disorder. Wherever you shall 
see it, you are to suspect its quality to be abnormal. 

Now that I have laid before you the analysis, and shown you 
what the material is, and hinted at the difficulty of examining it, I 
hope you will allow me to say a few words that are germain to 
those hints, and will not much interrupt the regular course of our 
studies of the subject. I wish you again to consider how difficult 
it is for us to be sure that such portions as we see are not diseased, 
or at least abnormal specimens. Let me beg you, in order to show 
how modest women are upon this subject — to remark, that while in 
this populous city, of more than 250,000 souls, half of whom are 
females, multitudes of them thronging the streets and the mar- 
kets, you never saw one of them, no, not one, who allowed a 
single drop to stain her stocking, or spot the thin dress that she 
wore. You never met with such an horreur at the cotillon party, 
nor with those who waltz or move in the Polka or Cachuca. I 
know not how I could give you a more striking proof of the re- 
gard, the respect, I was going to say the superstitious veneration, 
with which the sex observe all the obligations of a perfect conve- 
nance on this subject. The fact is, that the sex have learned by 
a time-honored tradition handed down through the mass of mind 
from age to age, that their life, health, comfort, fruitfulness, and 
beauty, have a strong alliance with, and dependence upon this 
office. It has become, therefore, a public sentiment — a female 
vox populi — vox dei, that commands it to be respected. Take 
good heed, then, that you always treat it with respect in your con- 



MENSTRUA. 413 

versations, inquiries and directions addressed to your patients and 
their friends and nurses. 

If I had time, I could give you an account of many supersti- 
tious observances and opinions relative to the catamenia that still 
linger even among some of the better informed people. To show 
you how ancient is the respect with which it is still regarded, you 
should advert to the story of Jacob and Laban. You remem- 
ber that when Jacob fled with his beloved Rachel, they carried 
off a part of the worthy father-in-law's images. 

In the 31st chapter of Genesis, the story is told in the follow- 
ing words: — "And it was told Laban on the third day that Jacob 
was fled. And he took his brethren with him, and pursued after 
him seven days' journey; and they overtook him in the Mount of 
Gilead. Now Jacob had pitched his tent in the Mount, and Laban 
with his brethren pitched in the Mount of Gilead. And Laban 
said to Jacob, what hast thou done, &c, &c. — yet wherefore hast 
thou stolen my gods? And Laban went into Jacob's tent, and 
into the two maid servants' tent, but he found them not. Then 
went he out of Leah's tent and entered into Rachel's tent. Now 
Rachel had taken the images and put them in the camel's furni- 
ture and sat upon them. And Laban searched all the tent but 
found them not. And she said unto her father, let it not displease 
my lord that I cannot rise up before thee; for the custom of women 
is upon me," &c. Here you see at how ancient a period it was 
a custom of women to be unwell — and what is more, you see a 
man who, with an armed force, had pursued his runaway family 
for seven days' journey, manifestly with the most violent anger, 
and eagerness to recover his idols. Yet, for the simple words, 
custom of women, he went out of the tent without making the 
lady violate the convenances belonging to her sexual custom. If 
she had not made this pretence, do you doubt that he would have 
dragged her from her seat to find the precious gods in whom he 
put his trust! 

The Hebrew Lawgiver doomed every Israelitish man to death 
that should lie with a woman at such conjuncture. 

The 15th chapter of the 7th book of Pliny, contains the follow- 
ing passage, showing what impression existed as to this discharge 
among a polished people. " But woman is the only menstrual 
animal; {solum animal menstruate,) and therefore the only one 
whose womb produces what is called a mole. A mole is an 



414 catamenia; 

amorphous mass of inanimate flesh, which can neither be cut with 
the edge, nor pierced with the point of a knife." 

"There is, perhaps, nothing in the world more monstrous than 
the menstrual fluid. Wine turns sour in its presence ; seeds, 
when touched with it, lose their germinative power ; hedges die ; 
and seeds planted in a garden where it falls are burned up in the 
ground. If a woman with the menses sits upon a tree, its fruit falls. 
Mirrors lose their polish, knives their edge, and ivory its bright- 
ness by its contact. Bees perish in their hives, and brass and 
iron are seized with sudden rust, and acquire a horrid odor if 
touched with the fluid. A dog that tastes it goes mad, and his 
bite is mortal," &c. The 7th chapter of his 28th book contains 
very copious details of the superstitious notions held concerning 
the menstrua centuries ago. 

The periodical discharge is an indispensable attribute of the 
sex — I mean the healthful part of them ; and no faith is to be 
given to the idle reports of travelers, who pretend that certain na- 
tions or tribes in the interior regions of South America are devoid 
of it. Nor is greater regard due to the oft-quoted notion of Roussel, 
that the habit of this discharge is not a natural one, but one ac- 
quired in past ages, and now become a settled and regular attri- 
bute. Roussel is celebrated chiefly for his small volume, entitled, 
Systeme Physique et Morale de la Femme, a work praised greatly 
beyond its deserts, although it must be admitted to be written in 
a very pleasing style. In Chap. II., of the second part, where he 
alludes to the hemorrhagies, by means of which men escape from 
the evils with which they are menaced in the shape of rheuma- 
tism, hypochondriasm, gout, and apoplexy, &c, he proceeds as 
follows : — 

"Women, from their sedentary and inactive mode of life, are 
less able to avoid them : the nature of their occupations favors the 
superabundance of humors which they possess in common with the 
male, instead of diminishing them, as is the case with the avoca- 
tions of men ; but then they have an excretory organ, by means of 
which they can be freed from the superabundant, and thereby 
hurtful humors. Animals that are not withdrawn from the empire 
of nature's laws, and who act under the guidance of instinct, have 
no need of this resource ; they are not, like men, liable to hemor- 
rhagies, nor, in consequence of such liability, to the morbific affec- 
tions which they serve to introduce. These hemorrhagies have 



CATAMENIA. 415 

become a necessary function, intimately connected with the hu- 
man constitution ; so that, in the present state of things, a woman 
is born with a tendency to have her menses at a certain age, as 
she is born with a tendency to take the small-pox ; for we can 
contract a new necessity as we can contract a new malady. Were 
it possible to review all the changes through which the human 
race have passed since their origin, we should, perhaps, discover 
that they have not been always the subjects of the same necessi- 
ties, the same functions, and the same diseases as at the present day. 
Having once contracted some vice of the constitution, or some 
new disease, which, beyond doubt, happens in all the species of 
animals, such vice, or such diseases, are transmitted from gene- 
ration to generation, and are perpetuated until some contrary 
cause arises to destroy them. This is the reason why races dege- 
nerate, and become changed in the lapse of ages. Thus the men- 
strual evacuation, being once introduced into the species, is com- 
municated by an uninterrupted filiation, so that we might say that 
a woman has her courses at the present era solely because her 
mother had them, just as she would have been consumptive if her 
mother had been so. And further, she may be subject to the 
menstrua even though the primitive cause that established this 
necessity of the female no longer subsists in her constitution. In 
fact, many women are regular who are not subject to plethora, 
nor a surcharge of humors. In these women the menstrual flow 
depends solely upon the habitual direction of nature's movements, 
like the periodical hemorrhagies that occur in men whose consti- 
tutions are already exhausted." 

Such are the views of the celebrated Roussel. You will readily 
perceive that if such modifications of the human nature, as he 
therein supposes to be possible, can actually take effect, there are 
no bounds to be set to the range of modifications possible ; and that, 
if Roussel's views are just, then the doctrines of the "Vestiges of 
Creation" are equally true, as to the gradual evolution of new 
specific and generic forms of creatures. 

It is not to be believed that Roussel would have entertained the 
opinion if he could have been acquainted with the functions of 
the ovaries, and the history of the early stages of the reproductive 
act. 

Having already drawn out this letter to a considerable length, 
I shall adjourn to the next a further consideration of the subject. 

I am, &c, C. D. M. 



416 EMMENAGOGUES. 



LETTER XXXII. 

Gentlemen : — The distinguished Professor of the Theory and 
Practice of Physic, in the University of Pennsylvania, Dr. Chap- 
man, begins, at p. 37, vol. 2, of his Discourses on Therap. and 
Mat. Med., an enumeration of the names and the qualities of the 
Menagoga, or Emmenagogues. The entire suite of his articles is 

1. Polygala senega. 

2. Juniperus sabina. 

3. Rubia tinctorum. 

4. Rosmarinus officinalis. 

5. Mentha pulegium. 

6. Secale cornutum. 

7. Helleborus niger. 

8. Cantharides, (perhaps.) 

9. Terebinthinous preparations. 

10. Phosphorus. 

11. Cold bath. 

12. Exercise. 

13. Change of air. 

14. Generous diet. 

15. Bark. 

16. The ferruginous articles. 

17. Fetid gums. 

18. Castor. 

19. Musk. 

20. Venesection. 

21. Aloes. 

22. Blisters. 

There, you have Dr. Chapman's list; look at it, study it, and 
when you have done so, ask yourself the question — is there an 
emmenagogue? No. Look at Murray's list, in his system of 
Mat. Med. and Pharm., at p. 284, vol. 1. Read over Cullen's 
list, with Professor Barton's additions; indeed, without reading 
anybody's list, reflect upon the causes of menstruation, and see 



EMMENAGOGUES. 417 

whether any animal, mineral, or vegetable thing is likely to make 
a woman menstruate. Cullen, after a long experience and prac- 
tice, with careful attention to collect results of this therapy, comes 
to the melancholy conclusion, that they are the most unfaithful 
of medicines, not answering to the hopes awakened by their repu- 
tation. 

I have long since arrived at the same conclusion; and you will, 
I suppose, remember how often I have expressed this disbelief in 
their powers, while lecturing upon the emmenagogues at the Col- 
lege. 

What then! is there nothing to be done for a retention of the 
menses ? Are we to say to the sick, there is no medicine for your 
case ? Far from it ; the sick require to be cured, and they may 
as often be cured of an amenorrhcea as of a rheumatism, or colic ; 
but emmenagogues will not cure them. Dr. Cullen, as I have said, 
placed no confidence in them. 

Upon a review of Dr. Chapman's list and remarks, you will 
readily perceive that he has little confidence in them, as little, 
perhaps, as Cullen himself; and yet you find that what with the 
lancet, the baths, the aloes, the blisters, the martial preparations, 
&c, he arrays a really powerful armament for the combat against 
the causes of obstruction. 

Yet the very array shows that Dr. Chapman seeks rather to cure 
the disorder which prevents the menstruation, in order that men- 
struation may occur naturally, as it will do in a healthy woman, 
than to compel the woman to menstruate first, in order that thereby 
she may be cured. 

Perhaps you would prefer to call a foot-bath, or a suffumigation, 
by the name emmenagogue! A woman of a very susceptible and 
delicate constitution, who should get her shoes and stockings wet 
in a sudden shower, is liable to have her courses stopped, with pain 
iii the pelvis, headache, and general soreness; and even some de- 
gree of fever. If she afterwards sit with her feet in a mustard or 
salt bath, for fifteen minutes — or, if she sit over the vapor of boil- 
ing water for half an hour — it is very likely the flow may return ; 
or, if she will place herself in a sitz-bath, or go into a plunge- 
bath at 100°, for twenty or thirty minutes, it is probable that her 
menses will return ; or, if she will take a large warm emollient in- 
jection, perhaps the flow will recommence; but if it does, will the 
effect entitle you to say that these remedies are emmenagogues ? I 
21 



418 EMMENAGOGUES. 

think not ; for they do not compel, they do not lead, they do not 
draw forth. Such remedies serve, by removing causes of obstruc- 
tion, or delay, to allow of the effectuation of the function. To break 
down a door, is a very different thing from unlocking it, and setting 
it wide open. These medicines, perhaps, may serve in this sense 
to set open the door; they do not break open, and thrust through, 
which is the idea and modus of a true emmenagogue. 

There are a great many cases of difficult, or suspended men- 
struation, that depend upon a rheumatic state of the womb. The 
pathological state of the organ preoccupies it, and brings it into 
a condition of sensivity and irritability incompatible with the per- 
formance of the mensual afct. I am well persuaded that much of 
the dysmenorrhcea we encounter, is rheumatic disorder. It is 
characterized by all the pains and fullness, and heat and pressure 
within the pelvis, of which we hear women complain, while they 
appear, in other regards, to enjoy very good health. The uterus 
becomes sensible upon pressure with the index finger ; a pessary 
in contact with it produces a sense of hot or burning pain, and 
yet the Touch reveals no change in the form, dimensions, or re- 
sistance of the vaginal cervix. I presume it is in many ex- 
amples, identical with what has been called irritable, or neuralgic 
uterus. It may last very long without change, and without in- 
ducing any cognizable change in the part. 

These are the cases that sometimes yield to the anti-rheumatic 
treatment. Is it not fair to presume that Dr. Dewees' vol. tinct. 
of guaiacum, w T hen it has done good in the dysmenorrhceas and 
suspended menstruations, has effected that good by virtue of its 
anti-rheumatic properties? I do not apprehend why the guaiac 
should possess any power to bring on menstruation, save that it 
has it in virtue of its anti-rheumatic therapeutical force. 

I advise you to study with care, in all your clinical cases that 
may be probably attributed to rheumatism of the reproductive 
organs, particularly the womb, the phenomena that may present 
themselves. You should carefully note, not only the signs given 
out by pain, and by suspended or altered function, but the influ- 
ence of remedies, for you may rest well assured that a great 
many cases of rheumatism of the womb have long been, and still 
are, commonly mistaken for prolapsions and other affections; a 
false diagnosis that leads to a false and unsuccessful mode of 
cure. Rheumatism of the w r omb is becoming a more frequent 



EMMENAGOGUES. 419 

object of inquiry than it used to be, and I am sure the subject 
is worthy of your special study and exploration. 

The gravid uterus is the frequent subject of rheumatic attacks, 
and it will be my duty to speak of it under the proper head. 

Meanwhile — if you find a patient complaining of pelvic pains, 
heat, weight, tenesmus, dysmenorrhcea, you would not be apt to 
make a mistake as to the true nature of the malady, should you, 
after due examination, come to the conclusion that you have a 
rheumatism to treat. Suppose you have made an examination, 
by the touch, and by external palpation, that you find the womb 
not displaced, nor at all disordered, nor swollen, and in addition 
to all this, learn that the patient has been subject to rheumatic 
pains, that she has accustomed herself to the use of the cold bath, 
that she is careless as to wet or damp cold feet, and that she 
wears no drawers, I see not what inference you could draw, save 
that she is rheumatic as to the uterus. 

If you cure the rheumatism the patient is cured, all the signs 
of a uterine disorder vanishing with the disappearance of the 
pain. But a local rheumatism may often be cured by a bath, or 
you may obtain great relief by the wearing of flannels. A wo- 
man with a rheumatic uterus should assuredly be directed to 
wear drawers of flannel, with a view to keep the pelvis, and 
loins, and thighs well covered and protected against the per- 
nicious influences of cold and damp. Such a patient should 
have a soluble state of the bowels, which may be obtained by 
any gentle aperient. If she have complained long and much, 
previously to your first interview ; if she be of a costive habit, 
and leave you to infer that some considerable accumulation of 
fseces has taken place in the colon, she should be purged, and 
well purged, as a preliminary treatment. There is scarcely to 
be found a safer or preferable compound for this purpose than the 
mixture of jalap and cream of tartar with oil of anise. Twenty, 
or twenty-five grains of jalap, forty grains of cream of tartar, and 
five drops of oil of anise, made into a powder, should be given 
for a dose, at an early morning hour. It may be expected that 
the dose shall operate five or six times. Two days later the dose 
may be repeated, and again in two days, which will probably 
suffice. After this let the patient take at bed-time an anodyne 
enema of forty-five drops of laudanum, with the view to abate 
the neuralgic sensibility of the parts within the pelvis. Let 



420 EMMENAGOGUES. 

her have a bath at 98° three times a week, before going to bed; 
let her keep herself warm as to her clothing; let her take sul- 
phate of quinine, or quinine and iron — and the disease can hardly 
resist the treatment. In fine weather it will be proper for her to 
exercise in the open air. The diet should be plain, but nutritious, 
and the treatment directed to build up the strength of the whole 
constitution. 

There are such things in medicine as sanguine determinations, 
as they are called. A sanguine determination to the head may 
exist, giving occasion to cephalalgia ; to flushings of the face ; to 
buzzing, or droning in the ears; to hemicrania; to sopor; to apo- 
plexy, or to coma. 

There are such things as loss of determination of blood to a 
part. All those people who complain of cold feet and hands, 
suffer from loss of determination to these points ; and they suffer 
so for months and for years. Now there is a great difference 
between the cases of excessive determinations to a part, and loss 
of determinations to a part. The former tends to procure exces- 
sive development; and the latter leads to debility, and even 
atrophy of the part. Well! a female may have an excessive san- 
guine determination to the pelvic extremity of the trunk, or she 
may suffer loss of such determination; if the former exist, she 
will be liable to excessive menstruation; if the latter, to amenor- 
rhoea. Suppose a woman to have an amenorrhoea from the latter 
cause; then you will increase the pelvic determination by hot 
pediluvia; by the hip-bath; by the use of frictions to the lower 
extremities ; by tight garters, or bandages on the legs ; by warm 
flannel drawers and stockings; by exercise on foot, which deve- 
lops the lower circulation; by galloping on horseback, which pow- 
erfully develops it ; by the dance ; and, lastly, by any medicines 
that tend to excite and stimulate the life forces of the pelvic ex- 
tremity of the trunk of the body. 

If a woman have a violent strangury, or a violent tenesmus, 
she will ipso facto have an augmented sanguine determination to 
the pelvis, its veins, and arteries, and capillaries. But there are 
medicines that give rise to these phenomena. The resins ; the 
balsams; spts. turpentine; cantharides; aloes. Such are the 
articles you would select. The tinctura sacra, spirits of turpen- 
tine, aloes, and assafetida ; Lady Webster's pills, oil of Juniper 
berries; Dewees' tinct. of guaiac, and tinct. of black hellebore; 



EMMENAGOGUES. 421 

all these articles tend to fulfil the indication, which is to augment 
the pelvic determination. If they do fulfil the indication, then, 
the forces of life and development in the ovary being remodified 
and reinstalled, the germ production will recommence, the ovula- 
tion and oviposit will be re-established, with monthly exactness, 
and the patient will have become regular again. 

A woman may miss of her monthly courses from debility ; what 
debility ! She may have been weakened by excessive menstrua- 
tions. She may have lost twenty ounces a month, for many 
months, so that -she has at last become really ansemical. Or she 
may have had a constant drain of blood from some hemorrhoidal 
marisca, or other excrescence ; or she may have been reduced by 
malarious fever, which has engendered an ague cake in her left 
hypochondrium. Her blood is reduced in its crasis by any of 
these, or by whatever cause. To cure such a case, bark and iron 
and wine and meats, and air and exercise, are the indications to 
be fulfilled by your authoritative prescription. 

I refer you again to the so often proposed dogma, or rather 
truth, that Biotic power is the result of the contact of oxygenated 
blood with the substance of brain. None of the innervations of 
your patient will be perfect and powerful, unless there be a just 
proportion between the dose of oxygen in the blood, and the 
Biotic power to be evolved. Your thin, pale oligaemic patient 
cannot take up enough oxygen out of the air she breathes, to make 
her strong. Let your business be, nay, let it be your sole busi- 
ness, to thicken, to enrich, to ensanguine her blood, in order that 
that rich and perfect compound, may be enabled to absorb, and 
take out of the circumambient air, the just and requisite amount 
of oxygen, wherewith to deflagrate, if I may so speak, in the 
brain, and evolve the Biotic, the life-force, the Lebens-kraft as 
the Germans call it. Meat and wine, and air and exercise, — bark 
and iron, the sea-bath, and mountain air, a cheerful spirit, an 
attention to the dress, soluble bowels, frictions of the skin — why 
need I enumerate all the things that might concur in the great 
end of improving the general health, which, being renewed, the 
menstruation follows, as light follows the uprising of the morning 



sun 



Examine your patient carefully, to learn whether the uterus 
may haply have become the seat of a chronic, inflammatory en- 
gorgement that tends to produce an hypertrophic state of the organ 



422 EMMENAGOGUES. 

which might render it disobedient to the normal influences that 
lead to the sensible signs of menstruation. In that case, should 
the state of the general health not forbid it, you would do wisely 
and well for the patient, should you take from the arm several 
ounces of blood, say from eight to sixteen ounces, in order to check, 
by such abstraction, the excessive vascular momentum directed 
upon the organ. I pray you be not afraid of the lancet; very 
few persons are hurt by the use of that fine therapeutical agent, 
whereas hundreds and thousands are permitted to lapse in health, 
and fall into a premature decay and death, from the want of its 
curative power. I implore you to study carefully the nature of 
the therapeutical effects of blood-letting ; endeavor to estimate its 
power over the Biotic forces ; try to comprehend how and why it 
is, that the abstraction of blood modifies the general innervative 
forces, and, so, modifies the life-force in a diseased part, and you 
may safely be trusted in the world with the lancet in your hand, 
which you will never, or rarely apply to the hurt, or the smallest 
injury of your patient, while on the other hand, you will permit 
many to perish, or fall into chronic ailments, worse than death, 
if you are timid, or ignorant as to the use of a remedy, which in 
all ages of the world has been, and in all future ages is likely to 
be one of the prime resources of our art, against a host of mala- 
dies that are indeed not to be successfully controlled by other 
means. 

I have heard that illustrious man, our countryman, Dr. Phy- 
sick, say — "it may be that, in some few instances, I have had 
occasion to think I have carried the use of the lancet too far; but 
I have to lament very numerous instances in which my timidity 
has prevented me from using it with sufficient boldness to save 
my patient from death." Such a saying, of such a man as Dr. 
Physick, is worthy of your hearing, and your heeding, for he was, 
take him all in all, a man of matchless wisdom and skill as a 
physician. 

In the further treatment of these cases of engorged uterus, with 
a tendency to hypertrophy, I advise you to make occasional ap- 
plications of leeches to the collum uteri. They are very readily 
applied by means of a Recamier speculum, to which is adapted 
a cylindrical cup, that fits into the-larger end of the tube. This 
cup, being filled with the required number of leeches, should be 
inverted into the speculum tube, after that has been so adjusted 



EMMENAGOGUES. 423 

as to receive into its uterine extremity the whole vaginal cervix or 
collum uteri. The leeches generally fill within thirty-five minutes, 
and often in twenty-five minutes, when they may be withdrawn 
together with the tube. 

In applying leeches to the uterus in this way, you should not 
use more than a dozen at a time, and I confess I have seen very 
copious bleeding produced by only one dozen American leeches. 
I have seen the hemorrhage go to the extent of causing most 
alarming deliquium, restrainable only by the tampon. Such 
accidents are, however, very rare, and only accountable for, by 
supposing that some considerable branch of the rete vasculosum 
of the vagina had been opened by the leeches. No danger need 
ever be apprehended from such an accident, provided you are at 
hand to obviate it, and that you can always do, as above said, by 
the use of a tampon. 

By means, then, of general bleeding, and the topical abstrac- 
tion of blood by leeches, you will probably in most cases succeed 
in reducing the vascular engorgement of the womb, and overcom- 
ing the sanguine determination on which it may have depended. 
Yet it is proper to secure the good end, by rest in a recumbent 
posture, and by the employment of purgative doses, particularly 
the hydragogue dose of jalap and cream of tartar, repeated on 
alternate days, for several days. These purgative doses, with 
the anodyne enemata at night, will restore the balance of the cir- 
culation, taking away the pain, heat, and pressure; after which, 
a regulated diet, and proper exercise and clothing, with the adju- 
vant power of bitters, or ferruginous tonics, will bring the patient 
up from the lowness brought on by the disease, and by the treat- 
ment, after which she may be expected to menstruate again. I 
shall here close this letter, with the assurance of the respect and 
esteem with which I am your faithful servant, 

C. D. M. 



424 MENORRHAGIA. 



LETTER XXXIII. 

Gentlemen: — The word Menorrhagia means immoderate flow 
of the menses ; which flow consists of a purer blood than that of the 
regular catamenial evacuation. The blood is purer, because the 
impetuous haste of the discharge causes it to come off' less mixed 
with cervical and vaginal mucus and epithelium, than in the more 
moderate or normal mensual hemorrhage ; — and this, I believe, is 
the only difference between them. As the blood in menorrhagia 
is less mixed and combined with foreign matters, you would 
naturally expect to find it to coagulate more readily; while this 
is quite true, it is not the less true that the real normal menstru- 
ous excretion does, in many women, coagulate, without any sus- 
picion of menorrhagia ; and it is reasonable a priori, to suppose 
so, since one woman may be seven days getting rid of her six 
ounces of fluid, whereas another woman will part with ten or 
twelve ounces, in three or five days. She who discharges the 
menses pleno rivo, will be sure to find some coagula; she who 
passes it slowly away, will find it to sink into her napkins with- 
out a clot, — for her blood has time to be much combined with 
mucus and epithelium. 

I should think you would not be surprised to learn that a woman 
may be now and then menorrhagic, because you would reflect 
upon the highly hemorrhagic nature of the womb — a very small 
organ supplied by two very considerable uterine arteries, and over 
and above that source, deriving into its sanguine circulation no 
small quantity from the inosculations of the ovarian arteries. 
Under such circumstances, and with the propensity to effuse blood 
established by the regular monthly habit of bleeding, women 
should be esteemed always liable to excessive menstruation, though 
the vast majority of them do escape any such inconvenience. 

In the case of epistaxis, one may readily acquire a sort of habit 
of bleeding at the nose, and the discharge in that case, differs not at 
all from that of the menstrua, except in respect to the nature of the 
epithelial desquamation, and, probably, also, some modified state 
of the admixed mucus. A patient shall bleed at the nose to the 



MENORRHAGIA. 425 

extent of losing an ounce of blood on one occasion, whereas on 
some subsequent one, he may lose a wash-basin full in a continu- 
ous rill; just so is it with the menstruating woman. When she 
bleeds just enough, just her accustomed quantity, it is all right with 
her; when she flows in excess, she is menorrhagic, she has menor- 
rhagia. The word is derived from the Greek p,q v month, and p^yvi^t 
to breakout. It is a true case of true uterine hemorrhage, though 
we are accustomed to call it menorrhagia, in order to indicate the 
opinion that it is connected with the mensual hemorrhage, and is 
not an accidental one. Hence, I advise you, when speaking of he- 
morrhages connected with the causes of menstruation, to call them 
menorrhagias, a word that expresses a whole phrase. It is a word 
that may be thus paraphrased. The woman is bleeding excess- 
ively, because the ovi-posit, in her case, has induced an excessive 
nisus hemorrhagicus, instead of the usual moderate and natural 
one; but when a woman bleeds because she has a phagedenic 
ulcer of the womb, or a detached ovum, or a polypus, or a bunch 
of hydatids, or a wound, then it is uterine hemorrhage. In this 
way you will speak with precision ; and if all our brethren w T ould 
be equally precise, there would be a better understanding of the 
meaning and value of the words menorrhagia and uterine hemor- 
rhage. 

Now the question comes up as to what can be the cause of a 
menorrhagia, and it is a question difficult, in many individual 
cases to answer. I say it is difficult to answer the question for a 
good many cases; in others it is not difficult. 

There are some women who have a very powerful systemic ven- 
tricle, giving a large, full, hard pulse, like the pulse of a synochus 
fort is. In such people, the blood driven forward by every stroke 
of the ventricle with a great momentum, reaches the distal parts 
of the circulation, with such a force of movement, that we need 
feel no surprise to find the hemorrhagic surfaces, once begun to 
bleed, continuing for a long time, and abundantly to discharge 
the sanguine fluid. 

Such hemorrhages are the common incidents of those persons 
who have hypertrophy of the left ventricle. In men, these hemor- 
rhages go to the lungs — the nose, the stomach, the hemorrhoidal 
vessels, or the brain; and are called henloptoe, epistaxis, hema- 
temesis, apoplexy, &c. In women, the same dangerous tendencies 
exist, but the habit of yielding to the force of the sanguine injec- 



426 MENORRHAGIA. 

tion of the uterine and spermatic arteries, causes them to be more 
frequently attacked with menorrhagia. In such a state of the arte- 
rial pulse, a menorrhagic attack is readily explainable by reference 
to the enormous force of the heart. 

It has been asserted that within two hundred years past whales 
have been captured of the length of three hundred feet, though it is 
at the present day rare to meet with a whale of seventy or eighty 
feet in length. The animal is so much sought for in the whale 
fisheries, that the large and aged ones have been in a good mea- 
sure destroyed, the captures amounting probably to ten thousand a 
year. But a whale of three hundred feet in length had an aorta 
of twelve inches in diameter, the blood of which w T as impelled 
like a torrent by an enormous systemic ventricle. The pow T er of 
that ventricle no dynamometer could estimate ; it must be enor- 
mous. My design in mentioning it is merely to suggest by it to 
your mind a reflection on the power of the systemic ventricle in all 
animals. That power in all the species should be conformable 
to the power of the tissues that receive the sanguine injection. 
Now, you can perceive, that in our case of menorrhagia the 
injecting force may far transcend the resisting power of the tis- 
sues, and the consequence might be, a menorrhagia lasting until 
the abnormal energy of the injection-power comes back to a con- 
formable degree. 

But there are some weak and very susceptible people, on the 
other hand, whose hearts are soft and gentle in motion, who 
nevertheless suffer from menorrhagia. For such people you can- 
not bring the excessive development of the heart to the solution 
of the problem. It is better, and more consonant to reason, to 
suppose that such patients suffer the excessive losses in conse- 
quence of an adynamic state of the womb itself, a state which 
enables a moderate force of arterial and capillary injection to 
overcome the barriers to hemorrhage that ought to be set up in 
the distal extremities of the vessels — vessels that ought to be 
strong enough to resist the hemorrhagic force, but are not, so that 
you have come to the conclusion that a menorrhagia may depend 
upon either an excessive power of the sources of the circulation, 
or upon an adynamic state of the organs upon which that circu- 
lation is directed. 

This last supposed case may be dependent upon some faulty 
action of the entire nerve system of the reproductive organs — a 



MENORRHAGIA. 427 

faulty state brought about by frequent pregnancies and abortions 
or labor — by indulgences in unlawful contacts — by excessive 
libidinous sensations — and lastly in the wretched class of public 
women, by the habits which ruin and degrade them both physi- 
cally and morally. 

Again, you may encounter cases of menorrhagia dependent on 
malignant disease, on typhus, on small-pox, on scarlatina, on 
cancerous vice — for all these maladies vitiate the blood, and pro- 
duce a state of the solids so utterly atonic, and of the blood 
so completely aplastic that it flows away passively, and soaks, so 
to speak, through living tissues that are already half dead. 

A woman may have a menorrhagia because she has a polypus 
growing within the womb ; I say a menorrhagia, for the polypus 
may be a firm fibrous tumor, very sparingly supplied with cir- 
culation in its own substance, and without any abrasion of its 
superficies that might cause it to bleed : and in this very case the 
womb shall be so vexed and so irritated by its presence and pres- 
sure, as to be the subject of a hemorrhagic nisus of the greatest 
intenseness, arising from the presence, the pressure, and the irri- 
tation excited by the tumor, and not from the tumor itself, so that 
the flooding is flooding of the womb, and not of the polypus. 
You should note this distinction, for you may meet with many 
polypes that bleed themselves, but which do not make the womb 
bleed. 

A sample of this sort was the case I mentioned at page 249, 
of my XlXth Letter, and I have seen many such. 

I fear, my young friends, that, like some older persons, you will 
not be so careful as you ought to be in making the diagnosis of 
our case. I will not say that it is always possible to make that 
diagnosis with absolute assurance, but I presume that where a 
perfect periodicity of the bleeding, I mean a catamenial periodicity, 
is observable, you will be pretty correct in resolving that it is a 
menorrhagic and not a hemorrhagic flooding. Indeed, it will, 
with such periodicity, be truly menorrhagic, even if the causa 
ipsissima be a polypus, a carcinoma, a gestation, &c. &c. If the 
case be not characterized by this periodicity it will not be men- 
orrhagic, but will, far more likely, on the face of it, wear the 
imprint of polypus, of ulcer, of vegetations, &c. &c. &c. The 
appearance, and the abundance of the discharge furnish no 
means of discrimination. 



428 MENORRHAGIA. 

In order to explain myself more fully, let me say that a hemor- 
rhagic nisus once set on foot does not, in some cases, exhaust itself 
for days, for weeks, or even for months, and yet the case is a 
case of simple menorrhagia. For example, I was, some time last 
winter, invited to give counsel to a lady, unmarried, aged about 
28, very fat, and even ruddy in complexion, and strong. She 
had not been one day without copious bloody flowing, for full six 
weeks, or forty-two days. I found her pulse not preternaturally 
full, but the rather, I found it to be quite conformable to the state 
of her general constitution. Still she kept on bleeding, as I said, 
for forty-two days, without a moment of intermission. My im- 
pression was, that the texture of the womb had, from some un- 
known cause, become relaxed so as to produce an hyperaemic 
state of the organ, which all the discharge was as yet unable to 
reduce. I asked myself this question.' — What does the lady re- 
quire for her cure — not what drug, but what change in any of her 
organs? Does the heart want any change? No; it beats well 
and temperately as I could desire. Is there any extraordinary 
excitability or sur-excitation of the nervous system in general? 
I can discover none. All the secretions are healthy; this issue 
of blood, which is completely blood, is the only fault. What is 
most likely to cure it? Anything that may condense the tissue of 
the womb, that may serve to make the womb smaller, harder, 
more solid, stronger — for the womb is composed of uterine tissue, 
with its vessels, nerves, absorbents, and cellular tela. What can 
I do to bring about this state of advantageous condensation of the 
womb? I can order cold baths, astringents, rest in a recumbent 
position, cool air, cold acidulated drinks, cold enemata — but, of 
all remedies, the most clearly indicated one is the secale cor- 
nutum — because, if that should have any effect whatever upon 
the womb, it would be the effect of condensing the uterine solids. 
I gave some vinum secale cornuti. She took a teaspoonful, which 
was repeated three times a day, and in two days her menorrhagia 
was gone and returned no more — vel post hoc, vel propter hoc. 
I say, vel post hoc, vel propter hoc. At about the same time I 
visited a maiden lady, 40 years of age, who had long led a very 
sedentary life. She complained of a constant discharge of her 
courses, as she said; and had not been free from a sanguine 
effusion for more than three months, nearly one hundred days. 
As the effusion was the sole symptom, save the accompanying 



MENORRHAGIA. 429 

debility, I felt that I had a right to regard it as a case in which, if 
the womb could be made to acquire an additional and normal degree 
of tonicity, the complaint would cease. I said, if secale cornutum 
has the same power to excite the muscular innervation of the non- 
gravid as of the gravid womb, it will probably fulfil the indication ; 
for, if the womb, in its substance, shall become condensed, all 
its parts will receive of the benefits of that condensation. I gave 
her vin. secal. cornut., a teaspoonful three times a day, and she 
told me after three days that her trouble disappeared, since which 
she has enjoyed her usual degree of health. Now, for my own 
part, I do not at all doubt the wine cured her, for here are tw T o 
clearly marked cases of the therapeutic effect of the drug speedily 
manifested; and for a great many years past I have occasionally 
found patients complaining in the same way, who have been in 
like manner cured. Pray, take notice of what I suppose to be 
the rationale of this cure, for it is for the sake of the rationale 
that I relate the cases. I wish you to understand, not so much 
that I cured these people, as the principles upon which I relied 
for their cure. I wished you to understand that a woman may 
have a menorrhagia because she has a flaccid, feeble, engorged, 
adynamic womb, just as an accouchee may have a post-partum 
hemorrhage because her womb will not condense itself; in the 
accouchee you will compel it to condense itself by various means, 
among which not the least nor last, will be the secale. 

Sometimes the secale fails to evince the slightest power over the 
non-gravid womb, even over the post-partum flaccid womb ; and 
in such cases, being disappointed of the condensing force of the 
secale, you must seek for other means of cure, requiring longer 
processes, such as styptics, tonics, cold, wine, and the best of the 
resources, as to certainty of operation — videlicet, the Tampon. 

Very young girls are, some of them, subject to menorrhagia. I 
have seen a girl under 18, using sixty napkins at every menstrua- 
tion. This young lady died about a year afterwards, with some 
physical alteration of the uterus, or ovary, I know not which, 
since she lost her life in a distant city. 

You will be very undutiful as physicians, if you do not attend 
to the greatest of all points of duty, I mean the establishing- a 
sound and true diagnosis. Remember the heart of the Bahrna 
mysticetus, and its artery a foot in diameter. If your patient's 
pulse and heart's throb, put you in mind of the Baleen a, you would 



430 MENORRHAGIA. 

bleed her, I should think ; you would lay her in bed ; you would 
exclude all stimulants, all conversation, lights, rich food, &c ; you 
would weaken her heart's injecting force by the lancet; and you 
would give her tartar emetic in small doses ; and digitalis, and cold 
acidulous and styptic, or hsem astatic drinks. Or, on the other 
hand, you would find her circulating power to be normal, and in 
that case you would not proceed as above, but you would apply 
styptics, cold, rest, opium, secale, &c. &c. 

As a general rule, I suppose that were a young person to send 
for you on account of a profuse menorrhagia, you would tell her 
nurse to put her to bed; to cover her lightly with bed-clothes; 
give her cold drinks, feed her sparingly; apply some cloths wrung 
out of vinegar and water, to the hypogaster, and tell her there is 
nothing to be feared. Such a counsel would, in most cases, com- 
prise nearly all you ought to do, or direct; but now and then you 
must go farther than this. 

I had a very extraordinary case under my care last winter, 
which I shall relate to you ; and I hope you will not find fault 
with my conduct in the case. 

A very delicate young lady, brought up in the lap of luxury 
and indulgence, and having at command all the advantages of 
fortune — possessed, of course, that nervous sur-excitability, that 
accompanies the higher advantages of the social state. Her 
age was eighteen or nineteen — an only daughter. Her weight 
about 88 or 90 pounds. She had had a two months' amenorrhoea, 
which was followed by a rather profuse menstruation, which 
was succeeded by a three months' retention, during which she had 
no occasion to complain of ill-health, beyond the mere fact of the 
amenorrhoea. At the end of the said three months, she had in 
the morning a very slight show, which she was glad to discover; 
and, upon consultation with the mother, went out to take a walk, 
hoping in that way to secure a good elimination, by setting the 
blood in motion. She did not go very far, and upon returning to 
the house was considerably more unwell. Early in the afternoon 
her mother sent me an urgent message. I learned that the dis- 
charge was excessive, with coagulations; but deeming it not at all 
alarming, I ordered her to be kept very quiet, in a low, recumbent 
position in bed. I gave her . some powders made as follows : — 
Take a drachm of alum and a scruple of nutmeg ; make a pow- 
der, to be divided into twelve parcels, of which one parcel is to 



MENORRHAGIA. 431 

be taken every hour, or every two hours, according as the flow is 
greater or less. She was allowed cold lemonade. 

At 10 o'clock at night I was recalled and found a great alarm ; 
a night-vase was filled with napkins deeply stained, and with 
many clots. The pulse was weakened*, the face pale, but the 
patient not at all disconcerted. There seemed to be no hemor- 
rhagic nisus discernible in the action of the pulse. There was 
no pain. 

The parents were deeply concerned, and asked me many ques- 
tions as to the danger, and the means to obviate it. I told the 
mother that the arrest was in my power at any moment. " Well, 
sir, why not use at once the means that may put a stop to so fright- 
ful a discharge?" 

In reply I stated that I did not deem it necessary now to act; 
for, there was reason to expect that the hemorrhagic propensity 
would soon be exhausted — that there were many therapeutical 
remedies of considerable force, and that I preferred not to resort 
to a chirurgical measure until compelled by the stress of circum- 
stances; for I should deeply regret to subject so young a lady 
unnecessarily to the Touch, without which the remedy in question 
was not to be applied. 

You will think it strange that I passed the whole night, until 
daybreak, in that apartment, and that I suffered the child to faint 
again and again ; opening the windows, using the fan, applying 
iced vinegar cloths to the hypogastrium and thighs, administering 
opium, sulphuric acid, and rose-infusion, taking the pillows occa- 
sionally from under her head, and vainly endeavoring to reassure 
the mother, who repeatedly entreated me to use the tampon, but 
I would not. Towards morning a remission occurred, and I went 
to my home. She was calm until after breakfast, when, upon my 
return to her chamber, she began again to flood and to faint, so 
that I was compelled to say to the mother that the time was now 
come to put a definitive stop to the hemorrhage, whose longer 
continuance would compromise the young lady. This informa- 
tion she joyfully received. 

When she had provided me with a bundle of old linen, and cut 
it into squares of four inches, many of them, I pushed them one 
by one, to the bottom of the vagina, out of which I first turned 
a handful of coagula. As soon as I had filled the vagina with 
the squares, I applied a napkin, folded up thick, in shape a 



432 MENORRHAGIA. 

parallelogram, that was carefully adjusted to the genitalia; and 
having secured the compress by the usual bandage very firmly 
drawn, the hemorrhage ceased. In twelve hours I withdrew the 
tampon; no flooding came on. In a few days the discharge 
ceased completely. I g&ve her broths and meats, and wine and 
iron, and she has been ever since in excellent health. 

There, gentlemen, is the unexaggerated history of the conduct 
of a case of menorrhagia in a virgin. I am ready now to say, 
that if I had such a case at this moment, I should treat it in the 
same way, as far as to the chirurgical part of the treatment. I 
do not regret that I allowed her to bleed so much and so long. 
I would permit another young lady to do the same thing, because, 
having confidence in the power of the tampon to suppress such a 
flooding, I would let her go very far towards a dangerous state 
rather than subject her to the mortification of the surgical inter- 
vention. 

As to the mortification which overtook her at last, you ought to 
reflect that it was sunk in the hazard. There was not, and there 
cannot be, any mortification for the mind when the consciousness 
of extreme distress or peril becomes the paramount sentiment. I 
have no doubt that the very perilous condition into which I al- 
lowed her to fall, had the effect of removing wholly the shock, 
and the vexation, and the shame, that would have wounded her 
had I, like a remorseless barbarian, subjected her unnecessarily 
to the Touch. 

I hope you will read this case with care. I say with care, and 
I mean to urge you, on the one hand, not to be too hasty with 
your chirurgery, and on the other hand, not to let your patient 
sink so low as to make it out of the question to restore her. You 
ought, in the beginning of your career to be ever thoughtful, ever 
circumspect, never in a hurry to decide — always allowing your- 
self time to study the state of the case, in all its bearings both 
present and prospective. A young man is as capable of doing 
this as an old one ; the only difference is, that the old man has 
learued to look about him, while the young man will not, in his 
hot and hasty temper, take time to think, but snaps at his con- 
clusions like a duck at a June-bug, as we used to say when I was 
a boy — excuse the homeliness of my simile; many of you have 
known it to be a common parlance, especially at the south; at 
least it was so forty years ago. 



MENORRHAGIA. 433 

Styptics, in uterine hemorrhage, are not of very great power. 
The mineral acids are about as good as any of them ; ten to fifteen 
drops of elixir of vitriol, diluted with a wineglassful of infusion 
of roses, makes a very good dose that may be repeated every 
hour or two. Five grains of powdered alum, with two grains of 
nutmeg, made into a powder and mixed in syrup, is a good dose, 
to be repeated hourly. I think, upon the whole, this is one of 
the best of the styptics. It is a very safe one. If you should 
make use of it in some bad case, and should find the flowing to 
continue notwithstanding your administration, take my word for 
it that you ought to make the patient swallow a large teaspoonfnl 
of the alum for a dose, and repeat it several times. It readily 
excites vomiting; indeed, there is hardly to be found a more 
powerful emetic. But, an emetic is a good therapeutic against 
a hemorrhage or menorrhagia, because the state of nausea, and 
the emulging influence of the act of vomiting, are capable of 
changing the determination of the blood, whilst it powerfully 
modifies the rate, not only of the heart's action, but also the rate 
and distribution of the innervative or Biotic force. 

Take, therefore, into your practice, the assurance that alum is 
one of your best medicines. See a paper on Croup, by my son, 
Dr. I. F. Meigs, in the Amer. Journal for 1847, for an account of 
the uses of alum as a remedy. 

Again, you have in opium a powerful modifier of the circu- 
lation. Opium always modifies the pulse ; it checks the hemor- 
rhagic nisus of the womb very effectually; think, therefore, of 
the resources you have in your hands through this drug. 

Sugar of lead is thought to be a very powerful article in the treat- 
ment of these hemorrhages. I do not like it, nor do I believe much 
in it; perhaps I have not dared to give it in excessive quantities, 
and having very rarely exhibited more than three grains in com- 
bination with opium for the dose, I am not sensible that I have 
ever been much struck with its haemostatic power, though I have 
made use of it many times, yet less frequently of late than in 
former years. 

The secale cornutum is a good and safe remedy ; I know of 
no objection to its use in menorrhagia; I ought, however, to say 
that if you make a false diagnostic, and give the patient secale 
when she is pregnant, while you deem her only menorrhagic, you 
will kill her child by making her miscarry. This you ought not 
28 



434 DYSMENORRHCEA. 

to do, for it is discreditable to you and to your art to make such 
a mistake. But having on a former page presented you my 
views on the use of secale, I shall not here iterate them. 

When a patient has recovered of the actual menorrhagia, 
you should give judicious orders as to her exercise, dress, food, and 
medicines, and take care, on the one hand, that the cardiac forces 
of the circulation become not again predominant in their power, 
and on the other, that the density or tone of the tissues of the 
body may be restored to a normal condition by those hygienic 
and therapeutic remedies and conduct that are suitable in the 
case. In all anemias, pure anemias, iron is the best of the the- 
rapeutic remedies — the wine, meats, baths, &c, are of the great- 
est importance in the way of the adjuvant ordinances. Farewell. 

C. D. M. 



LETTER XXXIV. 

ON DYSMENORRHEA. 

Gentlemen: — The Greek words Svj p^v psw mean — first, difficult ; 
second, month ; and third, I flow ; so that out of Bvspijvpea it was 
easy to make the word dysmenorrhea, which might be translated 
absolutely, a difficult monthly flow. 

DysmenorrhcEa is a more or less painful disease; sometimes not 
very much so, but not unfrequently so much so as to give a color 
of distress and affliction to the whole life of the patient. A lady 
said to me, some time ago, "Doctor, I have for fifteen years suf- 
fered invariably at my periods, such intense distress, that I can 
scarce think of anything else than that on a given day my pain 
is to be repeated; language is incapable of expressing the degree 
of torture which I suffer under the pain, the approach of w T hich 
fills me with horror." 

A woman who suffers dysmenorrhcea, is, ipso facto, unhealthy, 
as to the womb, and very likely to be unfruitful in the marriage- 
bed. It is true, that dysmenorrhcea may last for many years, in 



DYSMENORRHEA. 435 

certain persons, without bringing about any visible change in the 
health of the constitution, which remains vigorous and retains the 
normal powers of development, notwithstanding the invariable 
return of the pain at the mensual term. 

You are not, however, from this statement advised to take up 
the notion that dysmenorrhcea is an indifferent matter viewed in 
the aspect of its influence on the health and security of the pa- 
tient. 

The pain, the irritation, the imperfect performance of the func- 
tion, and the state of the tissues producing it, are, all of them, cir- 
cumstances well calculated to excite the solicitude both of the 
patient and the physician, because it remains everlastingly true, 
that the disturbance of the health of the reproductive tissues is 
very likely to exercise a disturbing influence upon the soundness 
and healthfulness of the entire rest of the constitution. 

The pain of dysmenorrhcea, is a pain felt in the hypogastric 
region, in either or both of the iliac regions, in the tractus of the 
ligamenta rotunda, in the sacral region, in the thighs, and very 
frequently in the course of the distribution of the obturator nerves. 
This pain, not unfrequently, extends to the whole belly, and is at 
times insupportable, from its violence. ; compelling the patient to 
lie down in the bed, or on the couch; forcing from her both tears 
and groans, and producing so great a degree of restlessness, that 
she seems to writhe like a crushed worm. 

As a general rule, it may be stated that, the pain is over in six 
or eight hours, and that it is rarely intense during more than 
twelve hours, while the painful sensations, however, may con- 
tinue one, two, or three days, and in some women through the 
entire progress of the catamenial act. A person who is subject 
to dysmenorrhcea, for the most part, finds herself relieved in the 
course of the first day, or as soon as the flow of blood becomes 
fully and freely established ; and regards herself not subject to 
considerable pain or inconvenience, until the cycle shall have 
brought back to her the hour of her affliction. 

There are hundreds and thousands of women, to whom the 
menses never bring any the least trouble or inconvenience; there 
are vast numbers of females, also, who are notified of the approach 
of their terms, by some sense of fullness and weight, or dragging, 
in the region of the pelvis; symptoms which disappear as soon 
as the nisus hemorrhagicus has effected the opening of the mouths 



436 DYSMENORRHEA. 

of the vessels, and begun to relieve the polygsemia of the repro- 
ductive tissues. 

The woman's womb aches until nature bleeds her, as the pleu- 
ritic man's stitch torments him until his physician opens a vein in 
his arm. If the menstrual flow succeeds in relieving the tumes- 
cence of the vessels of the womb, it will, pari passu, have relieved 
the nerves of the organ of their hyperaesthesia. The pain is of 
the nerve, and, I suppose, might be fairly attributed to the sort 
of compression which the distal extremities of the reproductive 
nerves must suffer in any case where an organ so solid in its 
tissue, so firm and elastic, as is the uterine texture, becomes the 
subject of a very decided polygsemia. 

I have already said that the uterus, or rather the reproductive, 
apparatus of the female, is extremely liable to that form of disor- 
der which is called rheumatism, a circumstance not to be won- 
dered at, in view of the manners and customs, modes of dress, 
and habits of the females living in the various latitudes in which. 
most of the people of Christendom reside. In those latitudes 
women are rarely clothed as warmly as they ought to be, custom, 
biensea?ice, the power of fashion, cause them to clothe the pelvic 
region of the body and thighs too lightly ; and the women who 
live in what are called the better classes of society, are constantly 
exposed to the morbific influences of cold and damp, applied to 
the lower extremities. 

The menstrual alternations of the life-force of the reproductive 
organs, which allows them never to continue in one even tenor 
of action, probably exposes them more peculiarly than other or- 
gans to the morbific, repercussive influence of cold and damp, 
which are admitted to be the most considerable provocatives to 
rheumatic disorders. 

Well, then, do you not perceive that a rheumatic womb is 
likely to be a painful womb during the menstrual act, and that 
much of the dysmenorrhcea which it will be your destiny to en- 
counter in your future career as practitioners, will be justly re- 
garded by you as a form of rheumatism ? Dr. Dewees was fully- 
convinced on this point. 

I am desirous to impress this notion upon your minds, my 
young friends, because if the notion be well founded, which I be- 
lieve it to be, I am sure that it will teach you in your therapeuti- 
cal prescriptions, and in your hygienical recommendations and 



DYSMENORRHEA. 437 

ordinances, to take such precautions, as may tend to free the 
patient from the essential element of her maladive condition, 
which is rheumatism. 

But there are many causes besides rheumatic vice, which may 
give rise to pains in menstruation ; doubtless the womb may be 
like any of the other tissues, the seat of a pure neuralgia, by 
which word, I mean a preternatural sensibility of the nerves of 
the tissues. Such a neuropathic condition would not fail to be 
aggravated, at the inception of that vascular engorgement which, 
under every theory of the function, is assigned as the antecedent 
or attendant of the monthly flow; and it is quite reasonable to 
believe, that the full establishment of the evacuation might be 
expected to relieve the woman from her neuropathic state. It 
may w r ell happen, too, that the patient may suffer pains at the 
menstrual crisis, dependent upon the temporary aggravation of 
evils, derived from the presence of 'tubercles, and of various hete- 
rology formations, to which the womb is not unfrequently found 
to be subject. 

A displaced or a deviated womb, is truly a dislocated w 7 omb ; 
but a dislocated organ cannot be supposed to have a healthful ex- 
istence, since such dislocation cannot fail to produce distortion 
and traction of the nervous tractus, which renders the organ 
liable to suffering, under changes of its sanguine circulation, and 
its innervation. 

A w T omb that is maintained at its proper height and in its pro- 
per attitude in the pelvis, will be, cseteris paribus, less likely to be 
the subject of dysmenorrhea, than a displaced or deviated one. 
A uterus that is retroverted w T ill scarcely fail to be a dysmenor- 
rhoeal uterus ; a uterus that is far prolapsed will rest with the os 
uteri upon the floor of the pelvis, and resting there for a longtime, 
the neck of the womb is likely to become bent at an angle ap- 
proaching more or less to a right angle. But, if the cervix uteri 
is bent at a right angle, don't you perceive that the canal of the 
cervix uteri is, by that very fact, placed in the condition of a 
strictured canal ? But, if you have a strictured canal of the cervix 
uteri, will not irritation in the body and fundus of the uterus, 
supervene from the difficulty which must necessarily ensue in the 
evacuation? Don't you know that a stricture of the urethra pro- 
duces irritation of the bladder, of the ureters, and even of the kid- 
neys, and will you find it difficult to suppose that a stricture of 



438 DYSMENORRHCEA. 

the canal of the cervix uteri, may, in the long run, lay the founda- 
tion for such irritation of the womb itself, as shall result in the 
establishment of a true dysmenorrhcea ? 

I don't pretend to say, that all the cases of stricture of the 
cervix uteri, are to be attributed to anteflexion or retroflexion of 
the neck of the womb, although those flexions are among the fre- 
quent causes. It is very certain, that some of the strictures of 
the cervix uteri are congenital ; you will admit that this is the 
case, because you already know, that congenital atretism of that 
canal, is one of the possible circumstances hereafter to attract 
your attention and call forth your skill. I have had several 
samples of great contraction among the anatomical specimens in 
my collection, and I have seen similar ones in some of the mu- 
seums of Europe. It was upon the observation of this constriction 
of the canal of the cervix uteri, constriction so great, as to make 
it not a little difficult to introduce a common pocket probe to the 
fundus uteri, that that most ingenious physician Dr. Mackintosh, 
author of the Practice of Physic, founded his successful treat- 
ment of cases of dysmenorrhcea. 

Dr. Mackintosh has given numerous cases of females, in 
w 7 hich he observed that the orifice of the canal of the cervix was 
exceedingly small; so small as scarcely to be perceptible to the 
touch : on pressing into that orifice a small bougie, which he car- 
ried up through the whole canal to the cavity of the body and 
fundus, he gently dilated the passage, which he fully dilated by 
successive operations, in which he employed larger, and still larger 
bougies, until the calibre of the passage was perfectly restored. 

The effect of these operations was to cure his patients of the 
most distressing and long-continued dysmenorrhcea, which serves 
conclusively, I think, to establish the theory which I am laying 
before you, namely, that stricture of the canal of the os uteri may 
be a cause of dysmenorrhcea. 

Dr. Mackintosh's practice has been used everywhere, and with 
undoubted success in cases proper for it. Some of the brethren 
have preferred to Mackintosh's method, the use of a concealed 
bistoury, which, being introduced to the upper extremity of the 
canal, is slightly disclosed by a spring, and then being with- 
drawn entirely from the os uteri, has divided the lining mem- 
brane of the canal, allowing of a complete dilatation of it. When 
I was in London, in eighteen hundred and forty-five, Dr. Locock 



DYSMENORRHEA. 439 

showed me one of these instruments with the effects of which he 
appeared to have been much pleased in his practice. 

If you have read this book, you must have observed in a former 
letter, that I strenuously opposed the use of all cutting instruments 
in the procuring of a requisite dilatation, upon the ground, that 
every division must be followed by a cicatrix, which is, essen- 
tially, a morbid existence; whereas all necessary dilatation can, I 
am convinced, be as readily and perfectly brought about by a dis- 
tending pressure, leaving the part, when the part has been thus 
cured, without a wound, and in a perfectly healthful and normal 
state. I repeat it, that a cicatrix is not a normal state ; it is always 
insecure, always dangerous. I, therefore, profess my adhesion to 
Mackintosh's practice. My own experience in the use of the bou- 
gie, has been to a certain extent satisfactory to me; satisfactory to 
this extent, that it has not only, in some cases, relieved the woman 
from distress, pain, and other disorders of menstruation, but that 
it has cured her of a preexisting sterility. A woman is likely 
to be sterile when her uterus is unhealthy, and particularly when 
it is unhealthy from narrowness of its canal. 

Within two months, there came to me from a distant state, 
after a correspondence which I had had with her physician rela- 
tive to her case, a lady complaining of dysmenorrhoea. She had 
been for fifteen years, perfectly regular ; she never failed in her 
menses; she could not remember a single instance of her cata- 
menia in which she had not suffered the most direful distress; 
her general health was excellent ; she had a lively, brilliant, com- 
plexion, a charming degree of embonpoint, but she had been 
many years married, and had had no children. After conversa- 
tion with her, she was willing to submit to an examination by the 
Touch, and afterwards by inspection by the speculum. I found, 
upon the Touch, that the os tincse rested upon the floor of the pelvis, 
where it had long rested; and I supposed that the weight of the 
uterus and the superincumbent pressure, had produced an ante- 
flexion of the cervix, bending it at about an angle of 110°. The 
opening of the os tincse was very small. Exposing that orifice by 
catching the collum uteri in the uterine extremity of a Recamier 
speculum, I pressed into it a linen bougie, which I conducted as 
far as the cavity of the womb. On the following day I repeated the 
operation, succeeding with a larger bougie, and the operations were 
repeated four times only, when I desisted from further attempts, 



440 DYSMENORRHEA. 

because her catamenial hour was nigh at hand. On the fourth day 
after the last operation, her courses appeared in due time ; they 
flowed freely, abundantly, and normally, and for the first time in 
her menstrual life, which, as I before said, had now continued for 
fifteen years, she passed through her menstrual crisis with- 
out the least uneasiness or distress, to her great satisfaction and 
that of her anxious husband. She soon afterward returned to 
her own state, promising me to keep me informed of the progress 
of the cure, since which I have had no tidings from her. 

I will not cram this volume with cases of an analogous kind, 
and in the treatment of which I have sometimes been so happy 
as to be very successful, while at other times my patient has not 
derived the least advantage from the process, probably because 
in the unsuccessful cases the remedy was not the one which I 
ought to have adopted. 

Dr. Mackintosh, at p. 655, Washington ed., informs us that he 
has treated twenty-two cases of dysmenorrhea by dilatation of the 
os uteri, of which eighteen were permanently cured. " Ten of 
these were married and living with their husbands; of these ten, 
seven subsequently fell with child." 

I have already asserted my belief that the uterus is the fre- 
quent subject of rheumatic disease. In the cases in which you 
may have reason to suppose that the malady is derived from a 
rheumatic vice, it will be reasonable for you to employ Dr. 
Dewees' celebrated volatile tincture of guaiac, on which, you 
know, he placed so great a reliance, but which, in my hands, I 
am sorry to say, has not fulfilled the high expectations which 
were derived from Dr. Dewees' lectures and publications. 

I think you will find advantage in using, a few days previous 
to the attack of dysmenorrhea, moderate doses of the golden 
sulphuret of antimony, combined with camphor and small por- 
tions of opium or morphia ; you will scarcely find an article 
possessing greater deobstruent powers, when an inflammatory 
excitement may be supposed to exist, than this special combina- 
tion, which not only has efficacy to soften the pulse, to increase 
the perspirability of the skin, and promote the secretions, but is 
also an efficacious agent in the subduction of the nervous excite- 
ment or erethism, which must be supposed in such cases. In 
any instance clearly traceable to a rheumatic condition of the 
fibrous texture of the uterus, and, in which you can indulge in a 



DYSMENORRHEA. 441 

hope of doing good by purgatives, allow me to suggest to you, 
the employment of Scudamore's mixture of acetous tincture of 
colchicum, magnesia, and sulphate of magnesia combined with 
some aromatic distilled water; you should for this purpose, com- 
bine three drachms of acetous tincture of colchicum, one drachm 
of magnesia, and three drachms of sulphate of magnesia, with 
four ounces of any aromatic distilled water, as that of mint, cin- 
namon, or what you will. The dose should be preceded by a 
moderate portion of blue pill, or calomel, to be taken at bed-time, 
while the colchicum mixture should be administered the following 
morning, in wineglassful doses, repeated every second or third 
hour until the operation is sufficient. 

It is important in all those cases where you wish to clear the 
reproductive organs of any accidental disturbing influence that 
may arise from irritation of the rectum, dependent upon accu- 
mulation of feces or improper excretions there, to move the ali- 
mentary passages as preliminary to some more, direct treatment. 
The mere removal of the heat and excitement dependent upon 
irritation seated in the lower bowel, may be sufficient to set the 
womb at liberty to perform its menstrual act without pain, or the 
least distress. 

I have already expressed to you my little belief in the power of 
emmenagogue medicines, without withholding my assent to the 
opinion that certain medicaments are endowed with the faculty of 
increasing the determination of the blood, and of the nervous force, 
toward the pelvic extremity of the body. I have found it safe, 
convenient and efficacious with this view, to administer for a long 
series of days, weeks, and even months, portions of the common 
tincture of Melampodium or black hellebore, and I confidently be- 
lieve that for different individuals to whom I have prescribed such 
medicaments, the result has been most fortunate. I have prescribed 
from fifty to sixty drops of the tincture to be taken thrice daily, 
with an infusion of some garden herb, as pennyroyal, and, either 
post hoc vel propter hoc, the patient, who had suffered the greatest 
distress from dysmenorrhoea, has been in different instances en- 
tirely relieved of her sufferings. This result I have obtained so 
many times, that it has become habitual with me to make the 
prescription where some other indication has not had the pre- 
cedence of it; such as venesection, purging, leeching, the bou- 
gie, etc. 



442 DYSMENORRHEA. 

I further believe, that the use of the ferruginous tonics in the 
cases where the crasis of the blood is so reduced as to warrant 
them, ought not to be omitted, and, that in a person laboring 
under dysmenorrhcea, and in whom it is right to prescribe the 
tincture of black hellebore, it will be, in general, right to prescribe 
Dr. Blaud's pill, of which one may be taken three times a day; 
or a pill composed of two or three grains of Vallet's mass, thrice 
daily, or, what, perhaps, is preferable to all the rest, two grains of 
Quevenne and Micquelard's metallic powder of iron. The patient, 
under these circumstances, in all the variable and cold seasons, 
should be compelled, as far as the authority of the physician will 
go, to wear drawers of woolen flannel. 

In the cases of dysmenorrhcea, in which there is pain in the uterine 
region during the intermenstrual period, and which is greatly aggra- 
vated during the menstrual epoch, an examination by the Touch 
might convince you that the organ is left in a subacutely inflamed 
state. In your treatment of an obstinate and serious malady of 
this sort, I should think you would deem it your duty to solicit an 
opportunity of inspecting the collum uteri, by means of the Re- 
camier speculum. It is not rare to find the interior aspect of the 
lips, and, indeed, the whole os tincae, red, turgid, and injected to 
such a degree, as to render the arterioles et venules visible, as 
you find them often in the chronic diphtheritis of the pharynx. A 
general bleeding, or a topical abstraction of blood, by means of 
leeches, are among the likeliest means to counteract this morbid 
state of the circulation of the parts, which, as long as it is allowed 
to persist, might effectually contravene your merely therapeutical 
efforts. To obtain a cure, bear in mind, also, I pray you, this 
solid therapeutical truth, namely, the nitrate of silver applied to 
a superficies, is among the most powerful, and least painful, of the 
antiphlogistic remedies in your power ; and that, in aiding to cure 
the topical affections of which the uterus complains, it will aid 
you to rid the patient of constitutional disturbances arising from 
those lesions. 

Many of these dysmenorrhceal patients complain of the dis- 
charge of shreds of an organized membranous material, which is 
doubtless the caducous coat of the uterus. If you don't like this 
term, caducous coat of the uterus, then, I beg you to say that 
when such a membrane is discharged in dysmenorrhcea, the half 
organized mass is not, and cannot be the result of coagulation, 



DYSMENORRHEA. 443 

but must be a plastic deposit, like the plastic deposit in croup, 
and like that in phlebitis, in pleuritis, peritonitis, &c, and ipso 
facto, proves the existence of an inflammatory state, because 
plastic deposits are not found, except in a condition which de- 
serves to be called an inflammatory condition. 

Dr. Dewees regards this excretion as derived from a rheumatic 
condition of the uterus ; you will see his reasoning on the sub- 
ject, at page 106 of his essays on various subjects, Phil. 1803, 
and you will find that he was led from a priori reasoning to make 
use of the guaiac in the cure of the complaint. At page 110 
is his formula for the preparation of his celebrated tincture, which 
is in the following terms : — 

R. — Pulv. gum. guaiac: Iviii; 

Carb. sodse vel potass : 3iij ; 

Pulv. pimentae ^iij ; 

Alcohol dilut. B>ij. 

The volatile spirits of sal ammoniac is to be added, pro re 
natd, in the proportion of from one to two drachms, less or more, 
agreeably to the state of the system. 

Dr. Dewees is justly to be regarded as one of the most emi- 
nent practitioners of midwifery in his day, and no American phy- 
sician has acquired a wider-spread reputation, either at home or 
abroad, than he. His opinions are entitled to respect, and I refer 
you to his article on dysmenorrhcea, which every student ought 
to read ; in that article you will find his directions for the admi- 
nistration of the volatile tincture of guaiac, with an account of the 
flattering results obtained from its employment. 

I do not consider myself as treating his memory with any dis- 
respect, when I suggest to you that it is rarely the nature of rheu- 
matism to produce plastic secretions upon surfaces, and that in 
none but the most violent examples of rheumatic inflammation, 
do we find plastic secretions, even about the articulations. 

Be careful, in all cases, about your patient's diet, about her 
occupations, and about her whole conduct; think always what you 
have to do, and how it is best to be done. 

I think, gentlemen, I shall have nothing further to say to you 
at present, of dysmenorrhcea. I am 

Very truly, 

Your obedient servant, 
C. D. M. 



444 CHANGE OF LIFE. 



LETTER XXXV. 

Gentlemen : — In this letter I shall speak to you on the " change 
of life," as it is commonly called, or that state of the female in 
which she finally loses the power of menstruation, ceasing from 
that time forth to be subject to the mensual evacuation of blood. 

If I have been correct in the opinion I have entertained, and 
which in former letters I have expressed, as to the causes of men- 
struation, then I shall have little to do in making you acquainted 
with the causes of the cessation of the menstrua, or change of life. 
For it is obvious, that if women menstruate because of the month- 
ly ovulation and deposit, they cease to menstruate because the 
monthly ovulation has ceased to be a Biotic function. 

I have all along insisted that the power of germ production is a 
climax of life-force — one that is only attained when the body has 
attained its full and mature development, maintained as long as 
that body retains its healthful vigor and force, and lost often upon 
the smallest change of the health, and given up definitively when 
the powers of life, having been exerted during the prime and ma- 
turity of the forces, begin to fail, and the possessor to decline to- 
wards the last term of existence, which is stated to be at three 
score and ten years. 

There is something melancholy in the conviction that must at- 
tend the final cessation of the menses, of a decadence of the con- 
stitution. The subject of such a conviction is compelled to admit 
that that she has now become — what? an old woman. Hence- 
forth, what has she to expect save gray hairs, wrinkles, the gradual 
decay of those physical or personal attractions, which heretofore 
have commanded the flattering homage of society — the slow aug- 
mentation of the burdens of existence — when the grasshopper 
becomes a burden — when the keepers of the house shall tremble, 
and they that look out of the windows shall become dim. The 
pearls of the mouth are become tarnished — the hay-like odor of 
the breath is gone — the rose has vanished from the cheek, and the 
lily is no longer the vain rival of the forehead or the neck. The 
dance is preposterous, and the throat no longer emulates the voice 



CHANGE OF LIFE. 445 

of the nightingale. All these are melancholy convictions, and 
not even the fine arguments of Tully, in his Treatise on Old Age, 
can drive away the painful truth or make the wrong the better 
reason. To be sure, religion can bring its consolations, its hopes, 
and its triumphs ; — for religion can make us triumph over death 
and the grave, robbing them of their sting and their victory. Still, 
human we are, and we shall be human while the clogs of mor- 
tality still hinder and bind us. 

What hope, then, has the woman who has come to the period 
of the change of life? Have you any comfort for her? Yes! 
She is no longer exposed to the direful risk and pain of child- 
bearing. She thanks God for that, and takes comfort in the 
thought. She is no longer to be the subject of the monthly trou- 
ble, which, while it lasted, and still held up her claim to be num- 
bered amongst the young, yet was often connected with sensations 
of ill health — which annoyed her by its failure — its procrastina- 
tion — its anticipation — its violence — its protractedness, and its 
pain. She has become fatigued with it, and tired of it. She had 
lost her color, and grown thin, for it exhausted and irritated her, 
but now that she has laid it aside for ever, her constitution no 
longer teased and taxed with the necessity, takes a new start of 
life and vigor; she begins to acquire a certain embonpoint, and, 
as Colombat beautifully depicts it, she seems to recover somewhat 
of the beauty, and grace, and attractions of an earlier date. Many 
women, in fact, do find that the health is greatly improved by 
the dispensation. The complexion recovers its former tint, and 
new deposits of fat give roundness to the limbs, and efface 
the wrinkled traces impressed upon the features by care, and 
watching, and exhaustion; so that, though the loss of the catame- 
nia brings wdth it the melancholy conviction that she is becoming 
old, there is a compensating conviction in the apparently renewed 
health and comfort that follows the change. A few short years, 
however, renew, but in a gradual manner, the evidences of the 
decline of life. 

But the sort of moral impressions of which I have spoken, and 
which, doubtless, are painful, are not the only evils to which the 
female is exposed at the change of life. I am sure that you will 
have no difficulty to conceive, that an organ, or rather a collec- 
tion of organs, that have been for thirty years concerned in the 
production of germs and in the performance of the great offices of 



446 CHANGE OF LIFE. 

menstruation, could not wholly cease from, and lay aside, those 
operations, on which have depended her health and security, 
without hazard, at least, or, perhaps, without some fatal lesion of 
her health ; and you should take into consideration, that during 
thirty years of menstruating and gestative life, the uterine arteries 
and nerves, as well as the spermatic nerves and arteries, have been 
subject to constant alternations of activity and repose. 

Should we not then be prepared to expect that, on the com- 
mencement of this long repose, these organs should become the 
subject of some unhealthy action of their innervative and circula- 
tive forces, laying the slow, insidious, but disastrous foundations 
of disease, which, too often, is not discovered or ascertained to 
exist, until it has passed beyond the curative stages? Such re- 
flections as these, it seems to me, ought to tend to render you 
extremely cautious in inquiring into the causes of those com- 
plaints which women at the change of life often make, and which, 
I am sorry to say, are as often hushed with the unsatisfactory reply, 
that such complaints are owing to the " change of life," and are 
likely to cease whenever that change shall become complete. 
A physician has no moral right, by his opinion, to put to sleep the 
anxieties of his patient, and to save himself the trouble of think- 
ing by so concise and unphilosophical mode of proceeding. 
"Whenever, therefore, a female at this period, which is universally 
admitted to be a critical and dangerous time for her, comes to 
you to complain of symptoms, referable to some morbid condition 
of the reproductive tissues, do you not perceive, that it would 
be most clearly your duty, to give a considerate attention to 
her relation, and not dismiss her until your judgment should 
be fully satisfied as to the therapeutical or hygienical indica- 
tions of the case ? It will not be necessary, in all instances of 
complaints made to you of uneasy sensations in the pelvic region, 
to subject the female to the pain and mortification of the vaginal 
Touch, but whenever the complaints are so considerable as to give 
you just reason to suppose that some congestive, or inflammatory 
modification of the reproductive tissues has taken place, it will 
be your duty to insist upon a full exploration of the state of the 
reproductive organs. Such an exploration, made in the manner 
already pointed out in former letters, will enable you to be per- 
fectly satisfied as to the existence of disease in those organs likely 
to affect the health of the patient. If, upon such an exploration, 



CHANGE OF LIFE. 447 

you should discover no reason to suppose that the organs within 
the pelvis are the seat of any morbid action ; then it will remain 
to you. to inquire into the state of the whole constitution of the 
patient. I have so often, in my lectures at the College and in 
this series of letters, pointed out to you the mode of making a 
diagnosis by the successive exclusion of all the organs and func- 
tions that you are enabled to pronounce to be in a healthful con- 
dition, that I need not here iterate the directions for making such 
a diagnosis. 

It might well happen, one w r ould think, that a female, who, for 
thirty years, had been perfectly regular in her menstrual function, 
and w T ho had, in a healthful manner, borne and nursed her chil- 
dren, might feel, upon the change of life, the loss of her accus- 
tomed evacuations. It is very certain that the habit of producing 
blood in quantities sufficient to carry on, in a healthful manner, 
all the ordinary life functions, besides yielding an abundant mate- 
rial for the monthly waste, is likely, upon the subduction of that 
w r aste, to be followed by disorders in the state of the sanguine 
mass. You remember the opinion so frequently expressed herein, 
that the blood owes its existence to the activity of the Endangium, 
or blood-membrane, as I have called it ; but disorders affecting 
that Endangium, modify the condition of the whole health. 

Under these circumstances, the health will be modified by a 
condition of the Endangium tending to produce, on the one hand, 
plethora, on the other, anemia. Now, you will find many of your 
patients complaining of ill health, and in whom it will be 
impossible to say that it is the brain, the lungs, the liver, the 
spleen, the pancreas, the alimentary tube, the great articulations, 
that are the seats of special malady, while the ill health is really 
due to a change in the crasis of the blood. But if the doctrine 
be true, that the Biotic force is a product of the contact or immis- 
cence of arterial blood w 7 ith the substance of the neurine, then 
it follows that you will have to discover the remedies, or the treat- 
ment that may serve to bring the blood back to an absolutely 
normal condition, which, when it shall have been effected, may 
serve to restore to the whole constitution, the salutary influences 
of a steady, perfect, equable innervation, which will be health. 

I beg you to consider that shock to the health which is the 
result of the change of life, and, acting upon the principles which 
I have just expressed, endeavor to bring about some modification 



448 CHANGE OF LIFE. 

in the alimentary apparatus, that may exert the proper force in 
the direction of the assimilation, and the hsematosis. 

This apparatus, in fact, may be said to stand at the very portals 
of existence, and any threatened invasion of the health is as likely 
or more so, to fall upon this point, as upon any other. Thus, in 
instituting inquiries into the state of the system in persons com- 
plaining of the change of life, it will be expedient for you to 
make inquiry into the wants of these alimentary organs. The 
peculiarity of their innervation and circulation, exposes them 
constantly to attacks of disease; this peculiarity consists in 
this, that, the whole of the blood of the digestive arteries, — which 
you may remember are the coeliac and the two mesenteric, — is 
carried back to the black circulation by the vena porta?, which 
trunk itself, is obliged to divide itself into a new series of venous 
capillaries, again to be assembled in the three hepatic veins, be- 
before it is finally returned to the right side of the heart. 

Do you not readily perceive that so complex a condition of cir- 
culation in those vessels, exposes them to constant engorgement 
and obstruction, interfering with the great restoring and replenish- 
ing power of digestion? 

Such disorders are frequently and carelessly expressed under 
the terms, biliousness, indigestion, flatulency, acidity, diarrhoea, 
costiveness, and it is not reasonable to expect, that they are to be 
instantly and promptly removed by the administration of one or 
two doses of some trifling aperient, or by the exhibition of the so 
much vaunted blue pill or calomel. 

The administration of a drug can never set aside the necessity 
for the observance of the reasonable rules of a hygienic method. 
Don't expect, therefore, to cure your patient, without a careful 
prescription as to her whole conduct in relation to her diet, to her 
dress, her baths, her sleep and waking, her exercise, and a pro- 
per attention to the state of the alimentary organs. 

By means of the exhibition of portions of blue mass, of calo- 
mel, of rhubarb, of the compound aloetic pill, and in weakly and 
cold persons, of some warm aperient tincture, such, for example, 
as a combination of the compound tincture of cinchona and 
tincture of rhubarb, in moderate doses, with wise prescriptions as 
to the nature of the aliment to be taken, you may hope to bring 
the digestive tube to a state of perfect health ; which, once effected, 
opens up the way to the removal of all the other difficulties that 



CHANGE OF LIFE. 449 

may have been connected with the development of the constitu- 
tional, or local maladies of the case. 

It will become easy for you to ascertain whether or no, the 
digestive functions are restored to a healthy condition. The 
signs of such a condition are found by making inquiry as to the 
state of the appetite, digestion, defecation, and the sensations of 
the patient as regards the abdomen and the health generally. 

Reference should be had to the condition of the strength, the 
color of the skin, its perspirability, its elasticity, its temperature ; 
the condition of the tongue, the state of the lining membrane of the 
mouth and fauces, as ascertained by inspection, and the odor of 
the breath ; the nature of the urine, as to quantity, as to color, as 
to solidity; the respiration, and the action of the heart, the great 
source of circulation, to be ascertained by direct auscultation, 
and by an examination of the pulse ; all these inquiries will give 
to you an answer to your question, — "how is the patient?" — and 
you will not lose sight of her, I trust, until the answer is entirely 
satisfactory to your mind. 

But there are circumstances, gentlemen, connected with the 
change of life, which often render it necessary for you to insist 
upon a direct examination by the touch as to the state of the repro- 
ductive organs. 

It will be rare for you to find, at this age, signs of leucorrhoea, 
or any follicular malady of these parts : such affections, I think, 
appertain to an earlier period of life. 

You will meet with some cases of great relaxation of the va- 
gina, which permits the uterus to fall down actually upon the 
plane of the perineal strait, or even, to take the position properly 
called procidentia. See Horace's Epodes, Ode viii. lines v. 
and vi. 

The uterus, fallen so far out of its proper position, becomes a dis- 
turbing force to the economy. I have already told you, again and 
again, that the nervous system of the womb and reproductive 
organs allies itself intimately to the system of voluntary and 
ganglionic innervation of the economy; and it is as easy to sup- 
pose that a female should feel perfectly well and comfortable with 
a dislocated humerus, as with a dislocated uterus ; for I deem it 
perfectly true to say, that a uterus fallen from its just level in the 
pelvis, is a dislocated uterus, a term which expresses the idea of 
29 



450 CHANGE OF LIFE. 

the case more completely and more trenchantly than the softer 
terms, uterine deviations and uterine displacements. 

I can't pretend to say, that if you would push the uterus back 
to its own level with your finger, and keep it there for a short 
time, your patient would be restored by that act to consum- 
mate health; but I repeat that a dislocated uterus is a disturbing 
force in the economy, and that whatever you may do or direct for 
the rest of her health, you will not be likely to have a perfect suc- 
cess, while you permit the unmitigated operation of that disturb- 
ing force. Therefore, in your plan of treatment, there should 
enter some means of placing the uterus in its natural position and 
retaining it so. The mode of effecting this desirable object, it is 
not necessary for me to dwell upon again in this letter ; therefore, 
I refer you to my letter on prolapsus, and the use of the pessary. 

If, in the case, instead of finding simply relaxation and dis- 
placement of the womb, you discover upon its ballottement that 
the uterus is heavier, larger, more solid, than it ought to be, you 
will at once inquire whether the state of the general circulation 
as to its force and vigor will warrant you %i prescribing a blood- 
letting, or whether you might deem it more prudent to let blood 
hy means of half a dozen or a dozen American leeches, applied 
to the collum uteri by means of a Recamier speculum, or whe- 
ther it might be deemed more advisable to take blood by means 
of cups applied upon the sacral region, or whether you will rely 
upon the resolvent influences of the warm bath, or of the applica- 
tion of some of the finer narcotic extracts to the interior of the 
vagina or the neck of the womb; such as injections of infusions 
of cicuta, — or extract of belladonna, or injections of laudanum 
into the rectum, — in the hope of effecting a complete subduction 
of nervous excitement and pain. 

Twenty grains of the extract of belladonna, mixed with two 
ounces of mucilage of gum, will furnish you a compound, of 
which, a tablespoonful may be injected into the vagina once or 
twice a day. 

Half an ounce of cicuta leaves may be boiled in half a pint 
of milk, which, when cold, should be strained, furnishing a liquor, 
of which half an ounce or an ounce should be injected into the 
vagina two or three times a day. 

If you prefer it, you may make use of an anodyne injection. 



CHANGE OF LIFE. 451 

made of forty drops of laudanum, mixed in half a fluidounce of 
boiled starch, to be employed as an injection, every night, and if 
necessary, every morning, of which you are to be the judge. 

As to exercise, and as to rest, under these circumstances, it is 
impossible for me to give you explicit directions, for these are 
momentous questions, which can only be decided in the presence 
of the patient, and upon a good acquaintance with her real wants 
as to those points. 

It is very certain, that a long recumbency in bed, or upon 
the couch, is frequently found to exert a salutary influence upon 
the congestive and inflammatory conditions of the uterus, doubt- 
less, in consequence of the beneficent influence of what is in sur- 
gery called position, upon the circulation of the blood in these 
low, dependent organs. 

I beg leave, however, to suggest to you a caution, as to the too 
long continuance of a confinement to the bed, or to the couch, 
which is dangerous to the health, since some exercise, some mo- 
tion of the body, some breathing of the fresh air of the open day, 
some relaxation from the perfect conviction of ill-health, only to 
be had in the conscious power of motion, is necessary to re- 
store the spirits of the patient, suffering under long chronical ail- 
ments. 

Instead of meeting with these relaxations of the vagina, and 
descents of the uterus, you will, about the change of life, meet 
with some cases of extreme constriction and condensation of these 
tissues. It has been my lot to encounter several examples, in 
which the greatest alarm and distress were, as I thought, trace- 
able to vaginal contraction and stricture. 

I need not dwell on the disordered mental impressions of the 
patient, connected with the reduction of the calibre of the vagina, 
amounting almost to a state of atretism. I am strongly inclined 
to believe that a case of melancholy, which led to suicidal pro- 
pensities and attempts, was justly attributable to such a convic- 
tion. Therefore, upon making such a discovery, I presume you 
would not fail to institute a treatment calculated to obviate such 
contractions, and I refer you to my letter No. IX., pages 88 to 90, 
for some directions as to the method of proceeding. 

Among the most frequent and dangerous accidents to which 
women who do suffer at this critical period of life are liable, is 
the laying the foundation of carcinomatous disease. You will 



452 CHANGE OF LIFE. 

remember that I have already expressed the opinion, that these 
frightful affections are the results, not of a direct inoculation of 
reproductive cells, but of slow changes of structure, brought 
about by unsuspected and unknown inflammations, which become, 
so to speak, the proper nidus, furnishing the requisite cytoblas- 
tema on which these cells depend for their development and in- 
definite increase. 

If, therefore, upon making your vaginal exploration and taxis, 
you discover some suspicious degree of hardening of the collum 
uteri, and especially of the os tincse ; if you find some change of 
the form of the mouth of the womb, altering its oblong, or its 
dimpled shape, rendering it irregular in circumference, and im- 
parting to the sense of touch the idea of botryoidal excrescences, 
or granules; then you will have just reason to fear that the fatal 
foundations are already laid; but, thank God, that as it is true, 
every swallow does not make a summer, so every suspicion of the 
commencement of carcinoma will not warrant the conviction that 
carcinoma is come. 

You will wholly fail of your duty, under such circumstances, if 
you omit to examine, by means of the speculum, the actual con- 
dition of the parts in question. 

For a woman who has a true carcinoma of the cervix, I believe 
there is no hope to be entertained ; but, be sure of the diagnostic ; 
and if you can flatter yourself, or convince yourself that the 
malady has not gone to the extent of clothing itself with the dire- 
ful characteristics of carcinoma, then there remains good hope of 
a cure, by a wise and careful treatment. 

If it is not carcinoma, what will you call it? Is there any 
other name by which it can be named, than the name of inflam- 
mation, whether you deem it acute or chronical? But, if it be 
inflammation, what remedies have you ? Have you not purga- 
tives? Can you not appeal to the aplastic powers of mercury, to 
the deobstruent therapeutical powers of the narcotics, to the anti- 
phlogistic uses of the lancet, the leech, the cupping-glass, the bath, 
emollient injections into the vagina, anodyne injections into the rec- 
tum, dietetic rules, and rest and reassurance of the patient? Have 
you not at hand the almost miraculously antiphlogistic endowment 
of the nitrate of silver ? I assure you that on many various occa- 
sions, in which, in persons approaching the change of life, I have 
on the first exploration been shocked by the conviction that the 



CHANGE OF LIFE. 453 

patient was attacked by carcinomatous degeneration of the ute- 
rus, I have, on further exploration and diagnosis, been led to 
the institution of attempts to cure, which have been entirely suc- 
cessful. 

I repeat to you here what I have said in a former letter, that I 
do not boast of curing cancer, but in the course of many years 
of clinical experience, I have met with many extraordinary es- 
capes from what I believed to be carcinoma, but in which I had 
doubtless made a false diagnostic. 

I shall not trouble you with further observations in this letter 
on the precise treatment of these cases, but refer you to the ear- 
lier letters of this volume for the principles and the treatment 
which you should adopt in their management — it would be but 
useless iteration to speak of them again here. 

And now, my young friends, comes the question, as to the time 
when the change of life takes place. As a general rule, it is safe 
to adopt a public opinion, though it may not be absolutely true 
that vox populi is vox Dei. 

That public opinion holds that the change of life takes place 
at forty-five years, and all our women look for the change at that 
time ; but all our women do not change at that time ; some women 
definitively lose their menstrua at thirty, and some even earlier. 
A lady with whom I conversed in March, 1844, told me that she 
became perfectly regular when she was twelve and a half years 
old ; she bore twelve children; at thirty-five she definitively ceased 
to menstruate, and in her whole life never had the least trouble 
with her menstrua; she was as well at its cessation and since as 
she ever was. She was upwards of 40 years of age. 

I have a patient now under my care, who at the age of 73 
years, is as regular as a young girl, and has been so since an 
early age. Allow me to cite for you a passage from M. Brierre 
de Boismont, p. 209. 

" It has been said in a general way, that the cessation of the 
menstrua takes place about the forty-fifth year in this country, — 
a little sooner or a little later: — the fact is true, but we believe 
that a better appreciation would be made by presenting a table 
indicating the different periods of the critical age; we have here 
collected one hundred and eighty-one cases of women indicating 
the age at which they had ceased to see, and here are the results. 



54 


CHANGE 


OF LIFE. 






At 21 — 2 


At 34—4 


At 42— 7 


At 50 — 


12 


24— I 


35—6 


43—4 


51 — 


4 


26 — 


36—7 


44 — 13 


52 — 


8 


27 — 1 


37—4 


45 — 13 


53 — 


2 


28 — 1 


38— 7 


46—9 


54 — 


5 


29—1 


39—1 


47—13 


55 — 


2 


30 — 3 


40 — 18 


48—8 


56 — 


2 


32 — 2 


41 — 10 


49—7 


57 — 


2 


Making a 1 


otal of 181. 




60 — 


1 



This informs us that the cessation of menstruation may take place 
at very different periods of life, since here we have cases showing 
that it may take place in years, varying from sixty to twenty-one. 
But the proportions at which it occurs at these several ages are 
very different, for, while it rarely happens in the young, it happens 
very frequently about the fortieth year, is very common about the 
age of fifty, at which time it sensibly diminishes, and in the last 
years of the table it follows the proportions observed in the early 
years. 

I will not trouble you with any further statistical details on this 
point, which I consider as useless, preferring to refer you to the 
voice of public opinion, which, you perceive by this table, coin- 
cides with the truth. 

You should be careful, in your early wants as to clinical expe- 
rience, not to take every assertion as the truth. A young Doctor 
would do well to adopt as his motto, the new-fangled French word 
Panoptism, which, to translate in an expression very common in 
America, would be set down in the words "wide awake." You 
are not to take it for granted, because a woman thinks that she 
has arrived at a critical age, that she is at the crisis ; you and not 
the patient, are to be the judge. If she be in the crisis, it is 
well, and you will act accordingly; you will not pester her with 
your vain emmenagogue treatment; if she be not in the crisis, you 
will provide such ordinances as may seem to be conformable to the 
requirements of the case. C. D. M. 



HYSTERIA. 455 



LETTER XXXVI. 

Gentlemen : — There is a disease called the Protean malady, 
because it simulates so many other disorders, that, like the fabled 
Proteus, it is assumed to be capable of taking on all forms. In 
common language, it is called Hysteria, from votepa, the womb. 
The ancients used to call it suffocation of the womb, suffocatio 
matricis, and prsefocatio matricis. It has been called itvii vatepixTj, 
and also arivovs axvoia; the rising of the mother; and an Irish girl 
who came to our clinique, in 1843, as some of you may remem- 
ber, replied, in answer to my question as to what ailed her, " The 
winding arrow, sir." "The what?" said I. "The winding 
arrow," rejoined her mother. "The winding arrow? I don't 
understand you," said I. " Why, it begins at the bottom of her 
stomach, sir, and it goes winding up along the course of her 
bowels until it gets to her throat, and then it chokes her, and she 
has a fit." So, we'll put down among other titles of hysteria, if 
you please, Irlandice, the winding arrow. 

The question that first presents itself, after pronouncing the 
word hysteria, and when a person has already some knowledge of 
the phenomena of the disease, is this, videlicet, is it hysteria ? 
that is to say, has the womb anything to do with it? and if the 
womb has anything to do with it, can a man, who has no womb 
at all, have hysteria ? This is a question which has long divided 
the profession. Many authors of rare merit, and great powers of 
discrimination, averring, that it is a hysterical, that is to say, a 
womb malady ; while others declare that it is wholly independent 
of the womb, and that males may have it as well as females. To 
reason this way, maybe said to be a reasoning after the Baconian 
or inductive method, which is not always the best way to reason, 
since a rational method may, in many circumstances, lead to re- 
sults as perfect, as clear, and as stable as those obtained by the 
most careful induction. 

If hysteria depend upon the womb, then a man, who has no 
womb, cannot have hysteria; then, hysteria, you will say, cannot 
depend upon a disturbing force emanating from the womb alone. 



456 HYSTERIA. 

We seem to have come to a term in speaking in this way; but 
we have not spoken the whole truth, because while hysteria may, 
in fact, proceed from the uterus, hysteria may, in fact, likewise 
attack the male. As to this point, I think there can be no 
doubt, since the medical records are full of testimony bearing 
upon it. 

The medical writers who have asserted that hysteria proceeds 
from the womb or the reproductive organs, — for which the word 
womb should be taken as a general expression,— have probably 
not understood themselves ; doubtless they have intended to assert 
that, modifications of the reproductive power of creatures, which 
might be characterized as the aphrodisiac sense, or, if you will 
have it, the aphrodisiac force, are the causes of the protean, or 
the hysteric malady. I say they could not really mean to say 
that the uterus alone, disengaged from, and unconnected with, 
the other reproductive organs, is, by its disturbing force, the cause 
of the hysterical malady, for that organ itself is probably far less 
immediately connected with the development of the aphrodisiac 
force, in the economy of creatures, than certain other parts, as the 
ovaria or clitoris, for example. But, as the constitutional aphrodisiac 
force is an appurtenance of both sexes, then, if modifications of that 
force can produce that malady, they may be deemed equally capa- 
ble of causing manifestations of the same phenomena in the male 
and in the female. To say, then, that an affection of the womb, as 
an organ, is capable of causing all the strange modifications of 
the innervative power, which are witnessed in hysteria, would be 
saying too much; but, the aphrodisiac power is, in some in- 
cognoscible manner, connected with a modality of the reproduct- 
ive apparatus as a whole, it would not be traveling beyond the 
record to say so. 

That force, you will not deny, is capable of influencing the 
whole physical, intellectual, and psychological nature of the sub- 
ject of it; and, if even the conscience and the free-will must be 
admitted to be subject to morbid modifications, what hardness do 
you find in admitting, likewise, that morbid modifications of a 
power, so intense, so universal, so determinative of the whole con- 
stitution, might be capable of exhibiting itself in any or all the 
parts of the constitution in the strange and, so called, incompre- 
hensible phenomena of the hysterical paroxysm? 

I have already told you, in former letters, that very slight 



HYSTERIA. 457 

modifications of the state of the womb, as to its level or its direc- 
tion in the pelvis, may exert a disturbing force upon the economy 
of the female, and it has been the custom, for two or three cen- 
turies past, to assign to the uterus the power of dispensing an 
aura, — which might be translated a vapor, or a halitus, — which, 
pervading different organs of the body, draws them into diseased 
sympathy with the distressed womb itself. This term, aura, is 
probably at the foundation of the word so commonly used in 
speaking of the maladies of females, I mean the word vapors, for 
a nervous, fitful, wayward woman is said to have vapors, — which 
I have regarded as synonymous with hysteria, — so that a woman 
with vapors is a woman who suffers from an aura hysterica, an 
exhalation, a halitus from the womb ; but we have got too deep 
into the nineteenth century, to entertain any further faith in the 
theory of vaporous exhalations from the organs, affecting other 
and distant organs. 

Nevertheless, this word, aura, may be admitted to have some 
usefulness, as it has an important signification in medicine, and 
is a common parlance, for it refers to the sensible progress of an 
irritation from some ascertained point of the body, to some other 
point, as from the womb to the throat, where it produces a phe- 
nomenon, called globus, or, from a distant point on a nerve in the 
leg or arm to the brain, resulting in epilepsy, from the os uteri to 
the pylorus, or the breast, exciting vomiting, in the one case, and 
tumefaction or pain in the other; and, so from one organ to some 
other organ, calling its powers into sympathy with its own. 

The dilatation of the cervix uteri in labor, is, by many persons, 
supposed to be the not unfrequent exciting cause of eclampsia, 
which it produces by disturbing the brain, excited beyond all 
tolerance by the pangs of the dilatation, which you might take as 
a strong example of the power of the aura hysterica. 

Let me repeat that the rigorous meaning of the term aura, as 
aura epileptica, aura hysterica, etc., was, that a vapor, a halitus, 
or an exhalation, arising from an organ, and proceeding to in- 
volve another organ within the scope of its influence, is the 
absolute cause of the morbid phenomena in the organ which is 
secondarily affected. Now this term does express the fact that 
the suffering condition of one part of the body is capable of call- 
ing into sympathy other and very distant parts. It might be 
better, perhaps, and more precise, to use the word sympathy to 



458 hysteria. 

express the idea attached to the word aura, and yet it is true, that 
in the case of what has been called aura, there is often a sensible 
tractus of irritation, or diseased perception, extending from some 
known leased point, as in the before cited case; there are pecu- 
liar sensations experienced, from time to time, when an aura, 
passing either slowly or rapidly, the whole length of a leg or arm, 
and rising to the whole height of the head, explodes — so to speak 
—in the frightful manifestation of an epileptic paroxysm. 

There is a most singular and most extraordinary exemplifica- 
tion of the influence of an excited condition of the aphrodisiac 
force, which you will find in the article Medication Antispasmo- 
dique, of Trousseau and Pidoux's Therapeutics. I will not cite 
it for you, but I advise you to take the first opportunity of read- 
ing it. 

You may remember that in the course of my lectures last win- 
ter, I cited to you as a proof of the most intense hysterical modi- 
fication, the condition of a woman in the last moments of the 
conflict of labor, and, indeed, I think that if you will revolve the 
whole scene of a labor in your mind, commencing with the first 
phenomena, and observing the progress and extension of the 
complication it introduces in the action of the various organs, you 
will perceive the most perfect example of the power of the repro- 
ductive system of organs, when excited, to call other portions of the 
economy into sympathy with itself. At the commencement of a 
labor all is calm. The first pain is felt in the cervix uteri, which 
is strained a little by the positive contraction of the fundus and 
corpus uteri, which strain, it, the cervix, simultaneously resists by 
its own contraction. From this point of the labor, through the 
whole series of influences exerted on the brain, the heart, the 
lungs, the exhalants, the temper, the intelligence, I shall not fol- 
low the changes; but I venture to say that should you practise 
midwifery, you will have many occasions to compare all these 
modifications with those of the most exquisitely marked hysteria 
— and be ready to regard them as proceeding from the same 
cause, videlicet, a modality of the reproductive apparatus, extend- 
ing its organismal influence beyond its own boundaries, and into 
the domain of other organs with which it has no direct anato- 
mical connection. 

I presume there are few practitioners of some years' standing, 
who have not met with examples in males, of disorder, so closely 



HYSTERIA. 459 

allied to the nature of hysteria, as to be with difficulty distin- 
guished from some of the forms of that affection. 

Dr. Marshall Hall, in his Principles of Diagnosis, p. 101, vol. 
i., has these words, in relation to hysteria: "It is almost pecu- 
liar to the female state." I have only to ask to what other sex it 
could be almost peculiar, and, if it be almost peculiar to the fe- 
male sex, does not Dr. Marshall Hall admit that it belongs also, 
in some degree, to the male sex? 

I saw within five years, a gentleman thirty-five years of age, 
who was married, and who had symptoms of insanity. When I 
was called to him, I found him insane with extraordinary halluci- 
nation. In consideration of his pulse, temperature, and intellec- 
tual disturbance, he was treated by bleeding, leeches, purgation ; 
which, together with a rigorous diet, w T ith rest in bed, restored 
him. The pulse, which was at first feverish and hard, became 
soft and natural; he recognized his situation and place, acknow- 
ledged the hallucinations with which he had been affected, and 
was soon after allowed to leave his room ; he rode out ; he walked 
out too much ; and having eaten immoderately, the fever was re- 
newed, and the same extraordinary hallucinations along with it. 
The excitement was so great, that it was found necessary to 
bleed, purge and confine him again to his bed. For the last three 

days ( ), after taking a good many doses of laudanum 

in ten drop doses, amounting to one hundred and forty drops in 
all, he was seized with a paroxysm, which I could characterize 
by no other name than that of hysteria. He had globus most ex- 
quisitely marked ; he had rhythmical beating of his breast with 
his right hand, frequent appearance of strangulation, and clutch- 
ing at his throat. These symptoms alternated with the most un- 
controllable laughter, followed by floods of tears, succeeded 
with laughter again, palpitation of the heart, and cold feet and 
hands, all of which continued to trouble him for nearly three 
days. The paroxysms were relieved after my visit, by a few 
ten drop doses of laudanum. 

In my note of the case, I found these words: — These phe- 
nomena are identical with those of hysteria in the female ; he 
says he has pain about the throat, the region of the occipital 
bone, and in the nucha; and he has a general uneasiness in the 
pelvis, strange sensations affecting the perineum, and this ac- 



460 HYSTERIA. 

companied with frequent erections. I suppose I have nerer 
seen a more manifest example of hysteria in the male. 

In conversation with him, I find that one of his hallucinations 
consists in a supposition, that all his late attacks of insanity were 
the effects of a violent attachment which he had formed for a very 
young lady, with whom, I believe, he is not acquainted personally, 
and with whom, I know, he has never spoken, though he thinks 
he has had this love for her for many years. 

I have reason from the above to suppose, that in this case, there 
is an aphrodisiac element of morbidity, which, if it be not "wholly 
causative of his disorder, yet exerts upon it a modifying power. 

The tremor of his lip in speaking, and the childish tendency to 
cry, remind me of the case mentioned by Sydenham, in his letter to 
Dr. Cole, on hysteria. The case of hysteria mentioned by Sy- 
denham, is found at the 320th page of Rush's Sydenham, Phila- 
delphia, 1815. It is in these words : — 

" And by the way I must observe that men are sometimes sub- 
ject to such crying fits, though rarely. I was called not long 
since to an ingenious gentleman, who had recovered of a fever 
but a few days before ; he employed another physician, who had 
blooded and purged him thrice, and forbid him the use of flesh. 
When I came and found him up, and heard him talk sensibly on 
some subjects, I asked why I was sent for, to which one of his 
friends replied, if I would have a little patience, I should be satis- 
fied. Accordingly, sitting down, and entering into discourse 
with the patient, I immediately perceived that his under lip was 
thrust outward and in constant motion (as it happens to fretful 
children, who pout before they cry), which was succeeded by the 
most violent fit of crying I had ever seen, attended with deep and 
almost convulsive sighs ; but it soon went off. I conceived that 
this disorder proceeded from an irregular motion of the spirits, 
occasioned in part by the long continuance of the disease, and 
partly by the evacuations that are required in order to the cure ; 
partly also by emptiness, and the abstinence from flesh, which 
the physician had ordered to be continued for some days after his 
recovery, to prevent a relapse. I maintained that he was in no 
danger of a fever, and that his disorder proceeded wnolly from 
emptiness ; and therefore ordered him a roast chicken for dinner, 
and advised him to drink wine moderately, at his meals; which 



HYSTERIA. 461 

being complied with, and he continuing to eat flesh sparingly, his 
disorder left him." 

Dr. Sydenham, from whom I have made the quotation, does not 
appear to suppose that hysteria is a disorder proceeding from the 
reproductive organs ; on the contrary, he says : — 

"Disorders, which we term hysteric in women, and hypochon- 
driac in men, arise from irregular motions of the animal spirits, 
whence they are hurried with violence, and too copiously to a 
particular part, occasioning convulsions and pain when they exert 
their force upon parts of delicate sensation ; and destroying the 
functions of the respective organs which they enter into, and of 
those also whence they come ; both being highly injured by this 
unequal distribution, which quite perverts the economy of nature. 

"The origin and antecedent cause of those irregular motions of 
the spirits, proceed from the weakness of their texture, whether it 
be natural or adventitious, whence they are easily dissipated upon 
the least accident, and their office perverted, for as the body is 
composed of parts which are manifest to the senses, so doubtless 
the mind consists in a regular frame or make of the spirits, which 
is the object of reason only. And this being so intimately united 
with the temperament of the body, is more or less disordered, ac- 
cording as the constituent parts thereof, given us by nature, are 
more or less firm. Hence women are more frequently affected 
with this disease than men, because kind nature has given them 
a finer and more delicate constitution of body, being designed for 
an easier life, and the pleasure of men, who are made robust 
that they might cultivate the earth, hunt and kill wild beasts for 
food, and the like." 

Among the samples of hysteria in the male, one of the most 
complete and perfect is by M. Louyer Villermay, in the Diction- 
naire des Sciences Medicales sub voce. 

The question resolves itself into this narrow compass; is hys- 
teria a disorder proceeding from a status of the reproductive system, 
by which I mean the reproductive force ? If it be not, then there 
can be no reason alleged why males should not be equally ob- 
noxious to it with females. Males are equally with females liable 
to apoplexy, to pleurisy, to bilious, typhous, and typhoid fevers, and 
to all the exanthemata; and, if our disorder is not a sexual, it is a 
non-sexual disease, and applicable to the race, the genus, and 
not to male or female. If you argue that the malady is really 



462 HYSTERIA. 

sexual or reproductive in its essence, then I don't see why you 
should not admit that though it be far more frequent, and far more 
intense in the female on account of the far greater development, 
alliance and importance of her reproductive system, it might be 
reasonably expected, that the reproductive system of the male 
should also manifest its power occasionally to disturb in a 
slighter, or less intense degree, since the relations of his repro- 
ductive apparatus are less extensive, and less impressive upon 
his organisms, than is the case with the female. He possesses 
neither the germiferous, the gestative, nor the lactative powers; 
nor has he any analogy to the great catamenial office of the fe- 
male. But, as I have already remarked, those great powers and 
functions cannot but have a vast influence over the whole of the 
organisms which, in their very creation, must have been en- 
dowed with a proper adaptability to the varying exercise of the 
general system of forces. 

It is impossible to reflect for a short time, one would think, 
upon the nature of the aphrodisiac infusion in the sum of the vital 
powers, without admitting that aphrodisiac power to be one of the 
most essential for the conservation of the species; that it is a great 
modifying principle, both of the. physical and moral character of 
the species ; and as such, has been recognized from remote ages. 
We control it in the domestic animals, by the various operations 
in which we quell it for the purpose of reducing them to a more 
perfect obedience, as well as for the purpose of modifying the 
nature of their flesh, and rendering it more valuable in the mar- 
ket. Hear how beautifully Virgil descants upon its powers in his 
third Georgic. 

Orane adeo genus in terris hominumque ferrarumque, 
Et genus aequorcum, pecudes, pictaequas volucres, 
In furias ignemque, ruunt: amor omnibus idem. 
Tempore not alio catulorum oblita leaena 
Saevior erravit campis. 

Nonne vides, ut tota tremor pertentet equorum 
Corpora, si tantum notas odor attulit auras ! 

Can the violent ebullition of life, so admirably described by 
this writer, be accounted for on any other principle, than that of 
some abnormal or at least transitory exacerbation of the inherent 
power and influence of the reproductive system, over the rest of 
the organisms? Do you think you can explain the many forms of 



HYSTERIA. 463 

excitement by merely referring to a modification of the systole of 
the heart, to a greater development of the calorific power, or to 
some sudden exacerbation of the general innervation, independent 
ot the action of this essential force ? Are they not explicable, rather, 
only in view of the impression made by the aphrodisiac sense on 
the entire community of organs ; lashing them into fury by its 
passion and touching them with the contagion of its own exagge- 
rated intensity. 

How can you reason upon the continued existence of the spe- 
cies, or their perpetuation upon the surface of the earth, with- 
out perceiving that their perpetuity could find its guarantee only 
in some great principle implanted deeply in the whole constitution 
of animals, able to exert, and able to manifest its might, dominion, 
and authority over their whole vitality. 

But where are the seat and throne of this aphrodisiac power, 
this sixth sense, this reproductive perception, this conservative 
force of species and genera, as distinguished from all other facul- 
ties and forces? It exists in the reproductive tissues, and if you 
will excuse the term, wraps them all in the embrace of its aura; 
it is diminished by their diminution, it is augmented, pari passu, 
with their development, and declines and dies with their extinc- 
tion. ' 

Have we not, then, sufficient ground here, to establish the opin- 
ion, that certain states of the ovaries, the womb, and its append- 
ages, may be sufficiently impressed upon the rest of the system, 
to waken among the organisms all those modified manifestations 
of vitality, which w r e observe with so much surprise in a parox- 
ysm of hysteria? 

I do not propose that, in hysteria, the womb is acutely or sub- 
acutely inflamed ; that it is in a hyposemic or hypersemic condition ; 
the question is, wdiether the womb is the seat of such a mode of 
vitality as enables it to impose upon other parts of the economy 
a touch of its ow T n distemper. 

Cannot the liver, the spleen, and the kidney do so, and shall a 
man deny to the stomach the power to distress the brain and other 
organs in states where its own apparent modality does not depart 
from the most healthful tone ? How, then, does the cephalalgia, 
the stupor, the coma, the precipitate movement of the heart, 
arise from the stomach, suffering, to say the least, no organic 
lesion, and evincing not the least sensible sign of disorder? It 



464 HYSTERIA. 

has been argued that the womb is not the seat and throne, the 
fons et origo, of hysteria, because we observe the most signal 
alterations of its texture, in disease, without the superinduction of 
hysterical affections ; as well might we deny the influence of the 
stomach upon the brain, because we find the whole pyloric ori- 
fice of the organ invaded by carcinoma, without the supervention 
of the least headache, or coma, or spasm. 

But it seems a waste of words to argue upon a point that might 
be readily settled by an answer to a question : Is a woman sub- 
ject to hysteria after the entire cessation of the menses? No! 

The causes of hysteria are to be found in a great variety of 
conditions, both of internal and external origin ; among them may 
be named a highly nervous and sanguine temperament, the patho- 
logical propensities of which are promoted by a sedentary life and 
luxurious living, hot rooms, hot beds, highly stimulating food, 
the use of wine, of aromatics ; a mind ill regulated, indulged, 
intolerant of control, highly impressible. In such an individual, 
any abnormal degree of excitement that might serve to add to the 
purely physiological action of the reproductive organs, you could 
well deem sufficient to send its aura forth upon its mission of 
mischief throughout the entire economy. 

The greatest degree of the hyperaemic excitement is in the hy- 
pogastric and pelvic regions ; but the blood is in commotion com- 
mensurably with the hypersemic status of the brain, and we see 
it rush in volumes to the vessels of the head, where it is mani- 
fested in the intense flush of the brow and the cheeks, and then 
commences the wild incoherent action of all the organs and func- 
tions that depend for their innervation upon the brain and cere- 
bellum. 

The whole spinal cord vibrates under the tension of the vital 
forces, roused to excitement by the reproductive and aphrodisiac 
power; cries, sobs, peals of immoderate laughter, tears in floods, 
stolid silence, perfect cataphora, spasm tonic or clonic, tetanoid 
closure of the jaws, the most extraordinary rhythmical movements 
of the symmetrical halves of the body, — zygozoar spasm, — rigid 
opisthotonos, sudden enormous meteorismus, profound coma, 
excessive secretion of limpid urine ; all followed suddenly by the 
profoundest calm of the constitution, and a feeling of the sweetest 
complacency and amiability. Such are the symptoms which 



HYSTERIA. 465 

leap, as it were, out of a profound repose, with a sudden and 
startling exaggeration. 

Mr. Georget, in his observations upon hysteria, positively 
denies the assertion, that any distress is felt in the hypogastrium, 
as asserted by Louyer Villermay, by Gendrin, and others ; but, I 
am equally sure, that I have had my hand grasped with the most 
spasmodic force by a very delicate lady, which, in spite of my 
efforts to the contrary, was carried and jammed into the hypogas- 
trium of the sufferer, and retained there, with violence, amidst the 
exclamations of " Here, here, oh! here!" 

I have seen three women, at the same moment, a mother and 
two daughters, all violently ill with aggravated hysteria, and all 
complaining of the most intense distress in the hypogastric 
region. 

I have, in my note book, under the date of September 5th, 
1842, the case of a young lady, stout, healthy looking, weighing 
about 130 pounds, subject to attacks of exquisitely marked hyste- 
rical passion — with sobs, laughter, and suffocation. In these fits, 
she always complains of something grasping her, — to use her own 
expression, — in the left hypochondrium, until she cannot breathe, 
and then suddenly letting go. I will not cite any further parti- 
culars of the case. 

There is connected with the aphrodisiac influence, a singular 
propensity in some females to simulate disease, and that, without 
any appreciable motive of interest. The skill and the persever- 
ance with which the deceptions are carried on, exceed almost the 
powers of belief. Dr. Locock, in that most admirable work of 
his on Hysteria, a work for which he ought to be immortalized, 
as proving in him powers of judgment, reasoning, and perception 
beyond what appertain to most mortals, gives us some extraor- 
dinary examples of morbi simulati. I must refer you to Dr. Lo- 
cock's book, a copy of which was published by my friend Dr. 
Bell, in that useful work, the Medical Library. It is within the 
reach of every medical student, and there is no medical student 
who should be without it. I have no time to cite those cases 
here. 

There are examples of women under the influence of what I 
believe to be the hysterical malady, who are capable of develop- 
ing physical disease upon the surface of the body by some power 
of the mind concentrating morbid actions upon parts of the sur- 
30 



466 HYSTERIA. 

face, producing there, the appearance of wounds. Such are the 
celebrated examples of the stigmated women, who, under an in- 
tense contemplation of the passion of the Saviour, have produced 
bleeding wounds in the palms, the soles, or even in the side : or 
at least seem to do so. We may believe this, sauf toujour s, the 
fact, that morbus simulatus, the malingering power, is capable of 
deceiving all mankind. Persons instigated by interested mo- 
tives, such as desire to be discharged from military or naval ser- 
vice, or to escape from the performance of disagreeable duties, or 
to excite the compassion of the public, are found to make use of 
extraordinary means of deception. But, I have no doubt of the 
frequent occurrence of malingering from hysterical causes ; as I 
have known young women to require the use of the catheter for 
months in succession, under a diseased conviction that the urine 
could not escape but by the aid of the catheter, I, being equally 
convinced, that it was an hysterical affection; a urinary mono- 
mania, in fact. 

I have seen a woman simulate the most intense spasm, fol- 
lowed by profound coma, pending which she endured, without 
wincing, the most painful treatment. In this case, although I 
suspected malingering at the time, I was wholly unable to verify 
it, until long after, when she confessed to me, that all her symptoms 
were assumed in order that she thereby might wreak revenge upon 
her husband, whom she wrongly suspected of infidelity. 

I have seen hysterical cough assumed and persevered in for 
many consecutive weeks, with such violence as to shock and ex- 
haust in a great degree the health of the sufferer. She was in 
an eminent degree, an hysterical person, and it is probable that 
she coughed three or four times a minute, save when asleep, 
during the whole of this time ; and I know it was a malinger- 
ing cough. In one unfortunate lady of great beauty and accom- 
plishments, subject to exquisitely marked hysteria, I was the dis- 
tressed witness of a fatal termination in consumption, of a cough 
that was merely simulated at first, under the impulsions of an 
hysteric state, 

What shall we say of the power of the aphrodisiac force when 
exaggerated into erotomania and satyriasis? — that power that 
drives from the conscience of the woman the last vestige of fe- 
male purity; and from her cheek the faculty to blush? The feats 



HYSTERIA. 467 

of Messalina are nothing to the manifestations of this power, 
sometimes met with in medical practice. 

The diagnosis of hysteria is in general not difficult. The 
means of distinguishing the hysterical convulsion from the ordi- 
nary epileptic form; the hysterical from the apoplectic coma; the 
hysterical tetanoid from the tetanic spasm, are to be sought for in 
the history of the case ; the sex, the age and sanatary habits, of 
the patient; in auscultation of the heart; in careful comparison 
and judgment of the pulse; in the condition of the calorific 
power; in the duration of the paroxysm; in a certain character 
of the physiognomical expression, where there is absence of all 
those profound and dangerous impressions which are inseparable 
from such great disorders as I have just named. 

In hysteria there is generally a moral cause, which sets in 
motion a machine already highly wrought and prepared for the 
movement. The hysterical woman, like the highly electrified 
thunder cloud, requires but the point to draw the flash. She sits, 
like Tarn O'Shanter's wife, 

" Gathering her brows f like gathering storm ? 
Nursing her wrath to keep it warm ;" 

when, suddenly and unexpectedly, some word, sign or gesture, or 
the failure of some word, sign or gesture, gives the occasion ; and 
we have reproaches, tears, screaming, laughter, sobs, w T ringing of 
hands, tearing of hair, clonic convulsions, tonic spasms, stupor, 
stertor, smiles like a May morning, loud laughter again, floods of 
tears, and then a gradual return to a state of gentle composure, 
wherein the tenderest affections of the female heart come to re- 
sume, w T ith unusual supremacy, their wonted sway over the soul. 
It is very true, that I have not always inquired, or have not 
upon inquiry, been always satisfied, as to the state of the uterus, 
and its appendages, in every case of hysteria that has fallen 
under my notice. But, I have in many of those cases, clearly 
discerned the connection between the morbid innervations and 
the known disorder of the sexual organs. In not a few instances, 
I have put a stop to the paroxysm of hysterical passion, by balanc- 
ing the uterus upon the point of my index finger, and thrusting it 
as far as I could carry it into the upper parts of the pelvic exca- 
vation ; thus relieving the innervation temporarily, from an irrita- 
tion of the reproductive apparatus proceeding from a prolapsion 



468 HYSTERIA. 

of the uterus, from which probably radiated the whole of the 
phenomena of the hysterical attack. 

With regard to the treatment of the hysterical passion, some of 
the cases require therapeutical treatment, and some not: a patient 
may be brought to herself by letting her alone and leaving her 
alone ; but in the wild and confused operations of the nervous 
and sanguine systems, with the impetuous force of the blood ob- 
served in some of the cases, there may be danger for some of the 
great vital organs. I have seen a case of pure hysteria resulting 
in coma, which terminated in the death of the patient, probably 
from sanguine extravasation in the encephalon. I believe that 
whenever the momentum of the blood is increased to a dangerous 
violence, by whatever cause, that danger ought to be obviated by 
the means best calculated immediately to reduce it within safe 
bounds. A simple antispasmodic medication will not do in these 
cases ; and I think you will not do your duty to the patient, under 
the circumstances, unless by means of venesection you take 
away from the brain and the heart, the material power to excite, 
and to stimulate. You will diminish the production of neurosity 
by diminishing the intensity of the contact of the oxygenated 
blood with the neurine. It is a very common opinion, that in the 
nervous affections we do wrong if we take blood ; and persons 
who dive not beyond the surface of things, for the most part hold 
to the opinion that you ought not to let blood except there be 
some inflammatory condition of organs, requiring that special 
therapia. I hope you will lay it to heart that a mere, simple, san- 
guine engorgement, the beginning of which has no connection 
with any inflammatory condition, or propensity, may speedily ter- 
minate in the ruin of the patient by allowing of effusions or extra- 
vasations, and that such propensities as clearly demand the use of 
venesection, as the most active and clearly marked inflammations. 
It is not true in fact that spasmodic, nervous, vaporous, hysterical 
disorders, neuropathias, require to be treated solely upon the 
principles of the antispasmodic medication, and he who adopts 
such sentiments, no matter by what school or by what authority 
they are instilled into his mind, thereby virtually ties up his 
hands in a thousand and a thousand instances, in which a perfect 
freedom from the bonds of such a prejudice, would render him a 
powerful and efficient practitioner of his art. 

If you should decide upon bleeding in any case of hysteria, 



HYSTERIA. 469 

you may, after the abstraction of blood, concentrate the confused, 
heterogeneous, disturbed perceptions upon a point, or points 
of the skin, by violent frictions, and slapping of the hands, 
or lower extremities ; by hot, sinapised pediluvia, by mustard 
cataplasms, by Granville's lotion, by the powerfully concentrat- 
ing sensation produced by the dry cup, especially if applied 
to the nucha, and on the interscapular region; after which 
you may avail yourself of the antispasmodic therapeutical power, 
which you can find in the assafetida, in the fetid gums, in 
castor, or in musk, or perhaps more than all in valerian, more 
particularly in the beautiful extract now prepared by means 
of ether. The inhalation of ether in this stage of the malady will 
be a safe and useful resource. I mean not the inhalation of ether 
to the extent of what is called etherization, and I advise you to make 
no appeal to such a power, since, — in the disordered and hetero- 
logy operations of the hemispheres, and of the tubercula quadrige- 
mina, of the cerebellum, of the spinal cord, and of what is always 
a deep participant in the hysterical manifestation, I mean the 
medulla oblongata, and the vagus — no man ought to arrogate to 
himself the right to plunge these organs into the temporary annihi- 
lation of etherization ; because, the co-ordination of their actions 
being destroyed in the hysterical paroxysm, there may be no re- 
gular succession in the influences of the ether upon the several 
parts of the brain. In that regular succession, the part that last 
yields is the medulla oblongata; what, if in this heterologue con- 
dition of the brain, it should be the first to yield ? It is the source 
of the respiratory power ; when it ceases to act, the respiration 
ceases; and is not a woman dead when the breath is out of her? 

I presume that there is not among the whole armamentarium 
medicum, an article possessing the exclusive properties of an anti- 
spasmodic so perfectly as valerian ; and I beg you again to take 
an early opportunity of reading Prof. Trousseau's remarks upon 
it, in his article on antispasmodic medication in his therapeutics. 

If you should resolve, in your cases of hysterical spasm and 
excitement, upon its use, I advise you to administer it as the fluid 
extract just before mentioned; or, if that be not conveniently 
attainable, to give it in. substance reduced to fine powder. 

A large teaspoonful of the fluid extract in a wineglassful of 
sweetened water, is a good dose, which may be frequently re- 
peated; or, a drachm of freshly powdered valerian root highly 



470 HYSTERIA. 

fragrant, may be divided into four powders ; of which, one is suit- 
able for a dose. Mix it in half a tumbler of fresh water, and 
make the patient drink it. Don't tell me that she can't drink it, 
or won't drink it; or that her jaws are set, and you can't make her 
swallow it. Her jaw T s will never be set so tight but that you can 
open them. How? Take two bits of ice, each as big as an egg ; 
w T rap each of them up in the corner of a napkin ; then press the cold 
napkin against her masseter muscles on each side. As a general 
rule, the cold contact will scarcely be made before, the masseter 
relaxes. But, suppose you find a case in w ? hich it w r on't relax; 
then, get the end of a spoon between her jaws, open them a little 
with this, and then substitute the end of a tooth-brush handle, 
now pour the liquid into her mouth: do you say she won't swal- 
low it? I reply she will swallow it, if with the end of the spoon 
handle you separate the base of her tongue from the velum pen- 
dulum palati, which will allow the mixture to get beyond the 
isthmus faucium, and when there, the oesophagus will transmit it 
to the stomach. 

Anybody can swallow ; I was almost ready to say, you could 
make a dead man swallow. I beg you never to say of your pa- 
tient, — he is past swallowing, — unless he be laboring under a 
paralysis of the pharynx and oesophagus; but you may practice 
for forty years, and never meet a case. 

But to return, if the patient does swallow the powder, you will 
probably witness a very speedy diminution of all the spasmodic 
innervation, and a return of the constitution to a state of the pro- 
foundest calm. 

Some time ago, I was summoned, in a hurry, to see a beautiful 
little child seized with most intense convulsions, brought on by 
her ingesta; among the attendants was a faithful nurse, who had 
lived a long time in the family — a highly hysterical and nervous 
individual. Having been very much excited and alarmed, on 
account of the condition of her little favorite, she w T ent into an 
adjoining apartment, where she fell into a most violent fit of hys- 
teria. My attention being called to her, I w T rote a prescription 
for half a drachm of powdered valerian, which w T as immediately 
brought to me, and I said to a young lady, standing near, " Please 
to mix the powder in half a tumbler of water, and bring it to 
me, and, with it, a tablespoon, -and I'll show you something 
very curious. Now, see here," — said I, — "here is this woman, 



HYSTERIA. 471 

whose mind, for the time, is abolished, and her body is, as you 
see, tortured by these violent spasms ; now, I'm going to make 
her swallow fifteen grains of the powdered root of valerian, and 
do you look on, to observe what strange powers are possessed by 
certain medicinal articles over the human body. You shall see 
that, in about fifteen minutes, this great storm shall become a 
great calm." The woman could not swallow, but I made her 
swallow the fifteen grains. "Now," — said I, — -"look at her." 
In two or three minutes, her spasms became less, and in a quar- 
ter of an hour, she was perfectly well. "Now, what do you 
think of that, my dear?" — said I. "I don't know what to think 
of it, doctor, but it surprises me very much." 

I have said nothing about opium ; what need have I to mention 
the name of opium in connection with such circumstances? It 
commends itself, by its very name, in all such cases ; provided 
that you can render yourself sure, that there is not connected 
with the paroxysmal manifestations, some element of meningitis, 
or cerebritis, which you have not deprived of its mischievous na- 
ture, by the salutary interposition of your lancet. 

With regard to the treatment of persons in the intervals of the 
hysterical paroxysms, to which they are liable, I should be guilty 
of the fault of iteration, were I to say much upon that subject, 
since I have so clearly expressed the conviction of my mind, that 
hysteria is truly hysteria, and not merely nervous sur- ex citation. 
But, if hysteria be truly hysteria, it follows that, in the intra- 
hysterical periods, you should address your inquiries and your 
remedies to the condition of the reproductive organs, and those 
morbid states which are the "ipsissima causa morbi." 

But I have spoken so much at length, in these letters, upon 
these morbid conditions, that I shall here close the present one, 
referring you to many of the antecedent pages of this volume. 

C. D. M. 



472 DISORDERS OF PREGNANCY. 



LETTER XXXVII. 

Gentlemen : — The change in the condition of the reproductive 
organs brought about by pregnancy, is too great to fail, in the 
majority of instances, to produce phenomena approaching per- 
haps to the nature of disease. 

It is necessary that the physician should render himself familiar 
with these phenomena. The pregnant state, in fact, is one full of 
interest to the medical student or the practitioner of physic. I 
feel it a duty, therefore, to say in these letters something to you 
of the state of pregnancy, and the maladies and the inconveniences 
with which it is accompanied. 

The fecundated germ, in attaching itself to the lining surface of 
the uterus, may affix itself to any part of the internal super- 
ficies of that organ. I say the fecundated germ, because I wish to 
express the opinion, that the germ may become fecundated with- 
out being followed by pregnancy. The germ is fecundated by 
the contact of the male sexual element, which imparts to it the 
power to develop the organisms, and the whole nature of the 
animal in question. But pregnancy cannot be deemed to take 
place, until the germ has established a mesenteric connection 
with the living surface of the mother. When, then, the mesenteric 
attachment takes place, the woman has conceived. Doubtless, 
thousands and millions of germs become fecundated, but which 
never form mesenteric attachments, and are consequently lost ; 
the womb is only pregnant when the mesenteric attachment is 
made. No matter where this mesenteric attachment is, the woman 
is pregnant when it is made. It may be effected in some part 
of the tractus of the Fallopian tube ; or it may be made upon the 
surface of the ovary, the ovary being covered at the time by the 
fimbria of the tube. If the porule of the Graafian cell have been 
formed, and the male sexual element have been translated through 
the channel of the tube, and come in contact with the exposed 
ovule, still contained within the Graafian crypt, the ovule maybe 
there fecundated, and may form its mesenteric attachment within 
the crypt, and then you will have an ovarian pregnancy, and there 



DISORDERS OF PREGNANCY. 473 

is not another way in which you can have one. It is probable that 
the germ may be fecundated within the grasp of the fimbria, and 
being thus endowed with the development power, it may fall into 
the peritoneal sack, and there form its mesenteric attachment ; thus 
constituting a ventral pregnancy. An ovule, on its passage from the 
fimbria to the uterus, may become fecundated; it maybe arrested 
in the narrowest part of the tube, where it passes through the 
thickness of the uterus ; the delay and the pressure are probably 
the causes why it sometimes forms its mesenteric attachment 
there, and develops itself in the substance of the uterus outside 
of its cavity, thus constituting what is called interstitial preg- 
nancy. 

Conception is never natural, never right, never safe, except 
when it takes place in the cavity of the womb. Please not under- 
stand me as stating, that fecundation always takes place out of 
the uterine cavity; it is probable that it most frequently takes 
place outside of the cavity, but it may take place within the 
cavity of the womb. The fecundation takes place in whatever 
place the contact of the sexual element happens to be made. 

When a woman has conceived, the womb begins to increase in 
size ; the increase taking place at first in the body and fundus, and 
not affecting the neck. This growth of the womb is so rapid, that it 
passes from the non-gravid state to the condition of the organ at 
full term of utero-gestation, in the short space of two hundred 
and eighty days ; a space of time in which the most remarkable 
changes occur in the character of the organ, and in the in- 
fluence of the organ upon the living economy. The non-gravid 
womb is about two and a half inches long, one and a half in 
the widest part, and one half an inch in thickness ; and its weight 
shall scarcely be found to exceed two ounces. The gravid womb 
at full term, is often twelve inches in length, and its transverse 
diameter is equal to eight or nine inches ; its weight, freed from its 
contents, is scarcely less than one pound, or a pound and a half. 
It exceeds by from eight hundred to twelve hundred per cent, 
its normal weight. 

The space occupied by it in the non-gravid state, is, as you 
have seen, very small; in the gravid condition it constantly in- 
trudes itself among the other organs, pushing them aside, dis- 
tending some, and compressing others, interfering with the flow 
of blood in the vessels and the ascent of the lymph in the tubes ; 



474 DISORDERS OF PREGNANCY. 

and calling out of the general source of the circulation vast tor- 
rents of arterial blood, which it returns to the venous circulation, 
after having deprived it of its oxygen, and of much of its elements 
of assimilation. 

Under such a view of the changes taking place in the womb, 
you have little reason to be surprised that the health of the 
woman is often disturbed. Do you imagine that the womb, when 
twelve inches in length by nine in breadth, and weighing a pound 
and a half, is the same organ that it w T as in the non-gravid con- 
dition? You call it, it is true, by the same name, uterus. But, if 
you inspect it, if you touch it, if you weigh it, if you analyze it, 
you will find it a totally different material. 

Why is it that the womb undergoes these wonderful changes of 
form, of dimensions, of weight? These changes are compulsory. 
The uterus has received the fecundated germ ; that germ is an 
animal, and was before it came into the uterus wholly independent 
of it; and will be while it remains in the w r omb, equally inde- 
pendent of that organ. That is to say, it w T ill be as independent 
of the uterus as the plant is of the soil in which it grows; if the 
plant be torn from the soil, it will perish, because it can nowhere 
find the materials for its development; and if the ovum is torn 
from its attachment, it will perish for a similar reason. 

The ovum grows by its own force ; it finds on the surface of 
the womb, the assimilative elements, which it knows how to 
assimilate for its own purposes. That assimilation, increasing 
constantly its weight and dimensions, it is inevitable that, if it is 
to reside in the womb, that organ must yield to the pressure of 
the growing ovum; and in yielding to that pressure, it is not de- 
stroyed; on the contrary, it is developed; it is augmented in size 
and in w T eight ; its uterine arteries and its nerves, and its absorbent 
vessels, all are increased, not in number, but in length and in 
diameter; greater quantities of blood furnish the material out of 
which this new growth takes place ; and thus the womb under 
the constant pressure of the augmenting ovum, is stimulated or 
excited to new efforts of uterine development force, — augmenta- 
tion. 

You know this to be true, because you know that the uterus at 
any period of utero-gestation has a constant tendency, I had 
almost said a constant desire, to return to its non-gravid repose. 
You know that it will begin to return to that non-gravid condition, 



DISORDERS OF PREGNANCY. 475 

whenever with the point of a bougie or other instrument you rup- 
ture the membranes of the ovum, and allow the watery contents 
to flow off. You also know, that it occasionally happens, that the 
uterus refuses to yield to the distention of the growing ovum, 
which is ruptured and expelled, or is even expelled unruptured 
by the action of the muscular womb. 

I don't know what better argument I can present to you in 
favor of the opinion I have expressed, of the compulsory nature of 
the uterine development in pregnancy, than the one above stated. 
If you remove the cause, the effect ceases, is an axiom in phi- 
losophy : I say, that the cause of the growth of th# uterus resides 
in the ovum, and I prove it by stating that whenever the ovum 
is destroyed, the effect of its growth, to w 7 it, the growth of the 
womb, ceases ipso facto. 

I wish to make this statement to you, simply because it is a 
physiological truth, but more than that, because it contains the 
most important chirurgical principle, a principle which you 
will apply a thousand times perhaps in your practice ; a principle 
which, if you understand it properly, shall give you the gratifica- 
tion of rescuing multitudes of people from an untimely grave, 
save you from the grossest errors in practice, and enable you to 
do honor to the divine art that you profess, by showing its might 
and its beneficence, upon the most interesting and important occa- 
sions. 

When the womb first begins to develop itself under the in- 
fluence of the growing ovum, it grows healthfully engorged, and of 
course grows broader, longer, and offers a larger surface of pres- 
sure to the superincumbent viscera. Both its augmented weight 
and volume, therefore, give it a tendency to descend toward the 
floor of the pelvis, and as it is attached to the bladder by the 
utero-vesical septum, and presses upon the rectum, which is both 
behind it and below it, the woman will scarce fail to have some 
symptoms of a prolapsus or descent of the uterus, evinced by a 
more frequent desire to pass urine, and a tenesmic feeling of weight 
and dragging about the loins, and in the two iliac regions. Such 
symptoms, therefore, in married women, or women exposed to the 
risk of conception, you should regard as rational or inferential 
signs of the gravid state; symptoms not absolutely to be relied 
upon, but still of no little value, when collated with those here- 
after to be mentioned. 



476 DISORDERS OF PREGNANCY. 

When the descent takes place, it happens, notwithstanding the 
augmented volume of the uterus, that the hypogastric region of 
the womb becomes less protuberant than it was in the non-gravid 
state ; so that the woman does not begin to grow larger, but really 
grows smaller in the early stages of pregnancy. Hence, the 
oft-quoted French proverb, 

"A ventre plat, enfant il-y a." 

Inasmuch, as I do not profess to know what the nerve force is, 
I cannot profess to tell you how it happens that the earliest 
modification of^the state of the uterus is so commonly expressed 
by simultaneous modifications in the stomach and in the female 
breast. If I use the word sympathy to express it, you see that I 
shall only use a word, and not give you an explanation. A man 
who thinks he has an explanation, because he has the word sym- 
pathy at hand, is like those people in the Old Testament, of 
whom the prophet says, "They fill their mouths with wind, and 
their belly with the east wind." It is better to say, and to think, 
that, as the life of the w T hole constitution is made up of the lives 
of all the organs and organisms which that constitution inholds, 
it is reasonable to suppose that the pathological condition of any one 
of the important organs may disarrange the normal, ordinary rate 
of action of some other, and even of all the other organs : life, 
in the womb, is, under this view, the multiple of the parts of the 
w T omb, and so of the assimilating organs, of the oxygenating or- 
gans, and so on ; but the life of one of the integers being disturbed, 
the multiple itself may be disturbed. If you have a cube made 
up of many smaller cubes, of which you take one away, or alter 
its form, it will no longer be precisely a cube ; so, if you alter the 
physiological condition of the uterus, by making it pregnant, you 
will disturb the rate of action in other parts of the economy, 
whose properties and powers are modified, because an important 
integer of that economy is changed. This is the best idea of 
sympathy that I can present, and now I am ready to say that the. 
stomach sympathizes with the uterus as the breast does, and 
that the sympathy is exhibited by anorexia, by acidity, by pica 
and malaccia, by nausea, by the most obstinate vomiting and by 
excitement of the salivary glands, to be looked upon as a part of 
the digestive apparatus; and so on to modification of the nutri- 
tion, the coloration and the calorification of the patient, as well 






DISORDERS OF PREGNANCY. 477 

as to changes both of her moral sentiments and her intellectual 
powers. 

The same sympathy, to use the word, introduces speedy modi- 
fication of the lactiferous apparatus. The milk granules of the 
breast glands, which have been inactive since the woman has 
acquired the menstrual power, or rather the ovulation power, now 
become roused into an active conformability to the wants of the 
constitution, and a new process of development is set up w T ithin 
them. This new force is manifested by an increase of the mag- 
nitude of the hemisphere of the breast, dependent more upon aug- 
mented deposit of adipose tissue, than upon immediate augmenta- 
tion of the lactiferous apparatus ; that augmentation is perceptible, 
but it becomes more strikingly so at a more advanced period. 

The new life moving in the female breast, also exhibits itself 
in increased deposit of pigmentum nigrum on the mucous body of 
the skin of the aureole which surrounds the nipple, and the whole 
aureole becomes protuberant, so as to represent a segment of a 
sphere smaller than the hemisphere upon which it rests. The 
numerous papillae which are observed near the margin of the 
aureole, feel the genial influence of the new excitement, and be- 
come decidedly developed in size. These mutations in the cha- 
racter of the female breast are such constant attendants even 
upon the earlier stages of gestation, that they afford strong rational 
or presumptive evidence of that state. Pray, my friends, perpend 
the words, presumptive or rational; and do not suppose yourselves 
authorized to decide the existence of pregnancy upon such grounds 
as these alone. It is but just to say that it deserves considerable 
reliance; so considerable that Dr. William Hunter, to whom w T e 
are all indebted for his great reputation, as well as for the valu- 
able works he has left to posterity, — was accustomed to pronounce 
from it alone. Upon one occasion, being in the dissecting-room, 
Mr. Clift showed him the body of a young female, and Dr. Hunter, 
upon observing the state of the aureole, which was deeply colored 
by a deposit of pigmentum nigrum, said to Mr. Clift that the 
young woman had died pregnant; Mr. Clift rejoined that it was 
impossible, since the hymen was still intact; notwithstanding 
that, Dr. Hunter insisted upon it that she was in a state of preg- 
nancy, and upon opening the body an early ovum was found in 
the womb. 

A woman who has become pregnant, has the womb occluded 



478 DISORDERS OF PREGNANCY. 

by the ovum, and even if the causes of menstruation still remain 
active, they cannot produce the bloody sign of menstruation, since 
the pregnant womb will not bleed: it may be the subject of the 
mensual engorgement, and doubtless is so; but, that mensual 
engorgement does not result in the menstrual hemorrhage, but 
it disappears after a few hours or after a few days. 

If the menstrual doctrine is true, this is reasonable. Of the 
truth of that doctrine, I entertain no doubt; and I believe you will 
find it everywhere admitted on the part of practitioners, as well 
as on the part of writers, that the early abortions are marked 
by a coincidence with the menstrual periods ; and it is but a fair 
induction that the menstrual effort overcoming the resisting power 
of the vessels of the womb, is often the real cause of the hemor- 
rhage of abortion. Hence, you make the inference, that women 
who are prone to abortion, ought to be protected against that 
danger by all the precautions that are convenient or proper at or 
about their menstrual periods. 

Supposing the woman to become pregnant, and that the 
succeeding menstrual effort fail, then she will miss of her ex- 
pected courses, and she will say, "I have conceived. 3 ' She 
will have good reason to say so, if the ordinary state of her health 
had given her good right to expect the normal return of her cata- 
menia, and if no accident or morbid cause whatever could be 
accused of intervening between her and her natural function. 

Upon missing the return, the woman, as I said, will suspect her- 
self to have conceived; but, as one swallow does not make a 
summer, so one failure of her menstruation will not give her as- 
surance that she has become gravid. To show you, however, 
how strong this presumption is, on the part of women generally, 
any one of the upper ten thousand will begin at once to make 
arrangements to procure her nurse, and to provide for the exigen- 
cies of her accouchement. If she have the morning sickness, if 
she have the darkened aureole, if the next menstrual return should 
prove a failure, the inference becomes stronger. If the third men- 
struation fail, with the same accompanying phenomena, and with 
the addition of some augmented protuberance of the hypogastric 
region, the inference that she is pregnant is greatly strengthened. 

The presumption that she is pregnant is strengthened by in- 
creased protuberance of the hypogaster and the other concomitants, 
and the more considerably if she fail at the fourth menstruation — 



DISORDERS OF PREGNANCY. 479 

still she does not know it. — At the fourth month, or more proba- 
bly at four and a-half, the child quickens, or, as the lawyers term 
it, becomes quick with life. 

Quickening has been understood in the world to mean that the 
child has become alive, whereas it was not alive before. The 
lawyers begin now to recognize its rights in court; whereas 
previously, it had not any claims of the State. They will hang 
you for maliciously killing it after this act of quickening, but they 
w T ill not call you in question on an indictment for the same act 
committed antecedently to the quickening. This is very great 
nonsense on the part of the lawyers, who would abolish their laws 
as to quickening if they understood the value of the term viability ; 
and they would transpose the claim to the protection of the State 
to the seventh month, or, more wisely still, make it commence with 
the conception. 

Quickening is, however, in its true sense, not quickening; it is 
only the first perceived motion of the foetus. There was motion 
before — but motion so slow, so feeble, that the impulses against 
the womb were not strong enough to be felt, or perceived. The 
child at four or four and a-half months has acquired so much 
muscular development, that it can thrust its feet out, or move its 
hands, or suddenly extend its whole trunk and limbs, so as to make 
the mother feel it. — That is quickening. But do you not know that 
some children weigh four pounds, some seven, and some twelve 
pounds at birth ? i . e. children grow faster and stronger in some 
instances than in others. Hence, it must happen, that the period 
of quickening will vary in different women, and in the same woman 
in different pregnancies. Whence, the woman may feel her child 
at three or three and a-half months : many have felt it at three 
months : or the child may be so small, feeble or torpid that it 
makes its spontaneous motion not perceptible till the fifth or even 
the sixth month ; and cases are recorded where it has never been 
felt until the birth had taken place. 

The quickening of the child generally removes all doubt as to 
the gravidity of the woman. She knows she is pregnant — for 
the child is quick with life within her womb. — I say she knows 
it — but you do not know it — nor have you the right to say that 
she knows it. 

Many a woman thinks she feels the motion of the child, when 
she feels some other motion ; and if you, relying upon her relation, 



480 DISORDERS OF PREGNANCY. 

or upon her good faith, should express your medical opinion, you 
might place yourself in a very unpleasant predicament. Suppose 
you rashly on oath declare to a court that you know her to be 
pregnant, when she is really not so, and knows she is not so! — 
Or suppose you assert she is so, and your professional oath serves 
to prove you rash or ignorant! Don't you see how wrong it 
would be to make professional assertions whose incorrectness 
must be exposed; and how much harm you do to yourself and to 
everybody else of the brethren ? The scoffer has words put in 
his mouth — and the despiser wags his head at us all. For, in 
the worldly sense, DOCTOR is a genus — and if the scoffer can 
scoff at you he can scoff at me, and all of us. Don't, therefore, 
by false diagnosis disgrace yourself, and disgrace me, who am 
your teacher and you my pupil. It would be reversing the axiom 
— "the children have eaten sour grapes, and the father's teeth 
are set on edge." 

Depend upon it, if you confide in the rational signs of preg- 
nancy, you will come to the day when you will be deceived. 

The signs of pregnancy are rational or sensible. I have 
mentioned seven of the rational signs, and two of the sensible 
signs — to wit, the swelling of the hypogaster and the quickening. 
There are other rational and other sensible signs. 

Toothache is a rational sign ; since there are many women who 
never become pregnant without having toothache. I have heard 
them say : "Each pregnancy has cost me a tooth." 

Hordeolum or stye, is also a sign, upon which women depend ; 
since some women always have a stye in the early stages of 
pregnancy. 

Ephelis, or the dark broad freckle which stains the brow, the 
cheek, and often the whole neck and bosom, is a sign, which in- 
variably accompanies pregnancy in many women: it probably 
consists in the deposit upon the inner surface of the skin, beneath 
the internal lamina of the cuticle, of a portion of pigmentum 
nigrum, and has an intimate connection with the operation of the 
same causes which invariably produce deposits of pigmentum 
nigrum beneath the scarf skin of the aureole. The deposit of 
pigmentum nigrum is everywhere augmented ; there is a con- 
siderable deposition of it always in the axilla?, upon the perineum, 
the external surface of the labia? pundendorum and the mons; 
and there is some connection, which it is difficult to explain, be- 






DISEASES OF PREGNANCY. 481 

tween the new life force set up in the constitution, and the increased 
deposit of pigmentum nigrum. 

One of the most common concomitants of the early stages of 
gestation, is that which I incidentally mentioned a little while 
ago : to wit, salivation. 

This probably has some connection with the disordered condi- 
tion of the stomach, brought on as symptomatic of the new state 
set up in the uterus by its gravidity. For the most part, it is 
merely an observable phenomenon, and does not call upon you 
for any therapeutical intervention; but the examples are by no 
means rare where it has actually become so distressing a dis- 
order as to require that you should give advice in relation to its 
management. That it has a connection with, and indeed an im- 
mediate dependence upon, the state of gestation, is to be inferred 
from the fact, that it comes on with the beginning of pregnancy, 
and terminates with the termination thereof. 

Here is an extract from my case-book. " September 6th, 1842. 
Last night I attended in her labor, Mrs. X: she was spitting 
saliva during the whole of the labor ; she says, and believes, that 
she has spit a pint and a half daily, for the last eight months. In 
the former pregnancies she spit about the same quantity; in both 
cases, the salivation ceased within three days after the birth of the 
child. This lady, in her pregnancy, therefore, lost 4,880 fluid- 
ounces of saliva, without appreciably acting in an injurious man- 
ner upon her health or strength. 

"Mrs. Y., in her last pregnancy, spit at least a quart daily, 
from the beginning to the end of the gestation. It ceased the day 
after the child was born. She discharged during her pregnancy 
at least sixty gallons of saliva, without making her the least weak 
or emaciated. This lady derived more comfort from keeping* a 
few grains of burnt coffee in her mouth, than from any other 
remedy that could be prescribed to her, or could be found out by 
her own ingenuity or experiment." 

I am sorry to tell you, that I know of no remedy at all to be 
depended upon for the management of these great salivations; 
they are the troublesome concomitants of the gestation, and they 
cease with the cessation of the gestation. They cannot be cured 
by alkalies or acids ; by venesection or purgation ; or by any the- 
rapeutical treatment with which I am acquainted. If it were 
just always to attribute the salivation to a state of the stomach, then 
31 * 



482 DISEASES OF PREGNANCY. 

it would be reasonable to apply remedies with a view to correct a 
faulty state of that organ, in hopes of curing the salivation. But, 
you will observe, that the patient whose case I last cited to you, 
computed that she lost sixty gallons of saliva during her gestation, 
without rendering her thin or weak. Her digestive powers must 
have been very energetic, to have prevented great loss of weight 
under such circumstances; and in fact her appetite was good 
throughout, and I believe you may calculate on finding it so in 
persons laboring under this affection. 

If I am right in this conception, don't you see how idle it 
would be to tease the woman with sickening drugs, in the vain 
hope of curing the salivation, dependent upon other causes than 
the state of the stomach? 

If you should meet with a state of salivation so great as to bring 
the woman's life into danger, you might confidently promise to 
cure it, if allowed to terminate her pregnancy by bringing on 
abortion. I am not to be considered here as advising you to 
bring on abortion or premature labor on account of salivation, as 
I presume such a thing has never been done ; I merely speak of 
it now as one of the possible resources of the art in very extreme 
examples. I mean, samples in which the health is so greatly 
endangered as to warrant you even in proposing so extreme a 
measure. 

The nausea and vomiting of which I made mention in an 
earlier part of this letter, although not so rebellious against 
treatment as the salivation of pregnancy, yet, in some cases, occur 
so excessively as to give great embarrassment to the practitioner, 
and great distress to the patient. There are many of these cases 
which are uninfluenced by any treatment whatever, uninfluenced, 
I mean, to any considerable extent. I attended, a few years ago, 
a lady in Arch street, who began to be sick at the stomach, coin- 
cidently with the conception ; there was no day in which she did 
not vomit, and it often happened that she vomited many times a 
day. When she had reached the full term of her utero-gestation, 
and had fallen into labor, the parturient force was very greatly 
contravened by the incessant sickness of the stomach, and violent 
efforts to vomit. I was so much annoyed by the perpetual irri- 
tation of the stomach, which appeared to me to protract her suf- 
ferings by interfering with the function, that notwithstanding 
she was a primipara, I resolved to violate the wholesome rule which 



DISEASES OF PREGNANCY. 483 

directs us not to rupture the membranes in primiparous women. 
From the moment that the gush of waters took place, when I had 
pierced the ovum, her sickness and vomiting totally disappeared, 
and never returned; the labor hastening to a favorable termina- 
tion in consequence of the relief of her nervous system produced 
by this discharge. 

You will sometimes be astonished to receive accounts from 
your patients of a vomiting that shall follow every meal; and 
upon careful inquiry it will seem, — but it cannot really be so, — 
that the patient shall throw up the whole of the ingesta. I had a 
lady, in Spruce street, under my care, in her sixth or seventh 
gestation, who, from the sixth month until the completion of her 
term, vomited soon after taking her food every day, and it was in- 
comprehensible to me, that under such circumstances she grew 
neither weak nor emaciated. 

I mention this case as having surprised me ; and you will find 
yourselves much surprised and embarrassed, when your patients 
apparently reject the whole of the ingesta. I have often been thus 
surprised during my long practice, and I beg you to believe when 
you shall meet with such cases, where, as I tell you, people 
seem to throw up all they take, and yet do not become emaciated, 
that, therefore, they do not throw up as much as they appear to. 

September 18, 1842, I made the following note in my case- 
book: Mrs. n was married three years ago, and removed to 

Texas. In the month of March she became pregnant for the first 
time; about the first of April she had sickness and vomiting, 
which she daily experienced. In June she came by steamboat 
from Galveston to New York, and thence to her friends here : she 
has been vomiting daily since the first of April. 

"How many times a day?" said I; "ten?" 

"Ten! why more than thirty." 

"What! thirty times daily since the first of April?" 

"Yes, sir, and more than that: I vomited every five minutes 
from New Orleans to New York, nor did I sleep one moment. I 
sailed from New Orleans on the 19th of June, in the even- 
ing, and arrived on the 27th, in the morning, at New York. I 
never slept; I vomited all day, and all night." 

Her mother, who was present, says, " for many days toge- 
ther, I am sure that she has vomited more than sixty times a 



484 DISEASES OF PREGNANCY. 

day, and after straining long, she often brings up a thick, brown- 
ish, rust-colored, ropy fluid, at times stained with blood." 

A very large wash basin filled with this substance stood by her 
bedside; she is thin, but not very. I found her with a hectical 
frequency of pulse, and a red tongue : she has constant saliva- 
tion, amounting to more than a pint a day. Any rude motion 
of the child makes her stomach sick. She has distressing cardi- 
algia: her bowels are regular. I ordered for her a mixture of one 
drachm of carbonate of potassa, forty drops of laudanum, and 
six ounces of spearmint water, of which she was to take a table- 
spoonful occasionally. She could not take it, as it made her sick. 
On Tuesday I directed her to drink freely of champagne ; the follow- 
ing Friday she was very cheerful, had slept well, had eaten well, 
had not vomited, nor been sick at the stomach. She had been 
taking anti-emetic remedies, under the care of one of my friends, 
for six weeks without benefit; the champagne seems to have 
been a perfect remedy thus far; but I fear it will not hold. 

On the 19th of September, I note, that she vomits no more, 
that she has a good appetite, sleeps well, is not sick, and has 
taken the contents of a basket of champagne. She stopped 
taking it two days ago, and became sick ; the champagne was 
repeated ad libitum, that is to say, very freely, and her stomach 
recovered again. She rode twenty miles to a funeral without in- 
disposition. She returned to the city sick again, and then vomited 
until the child was born alive at full term. When she had com- 
pleted the eighth month, I w T as strongly tempted to bring on pre- 
mature labor ; but she went to term, and got well. The child 
was unhealthy, and was covered with pompholyx and eczema; 
and died at last of atrophy. 

I have given you the trouble, gentlemen, of reading this long 
extract, for the purpose of showing you that the vomiting of preg- 
nancy, may, by the long protraction of the malady of innervation, 
pass into a true gastritis, or gastro-enteritis, w T hich was doubtless 
the case with the lady whose history I have just related. You see 
that I could not cure her gastritis, while her pregnancy continued, 
though I suspended it for a while by the use of the champagne, 
which, all things considered, I find to be the best anti-emetic in 
these vomitings. I don't mean to say that it is always sure, 
but only that it generally succeeds. I have, at this moment, 
October 18th, 1847, under my care, the case of a young lady, 



DISEASES OF PREGNANCY. 485 

suspecting herself to be in the third month of pregnancy, and 
whose symptomatic vomiting has reduced her to a very ex- 
treme degree of emaciation, and whose stomach will by no means 
tolerate the champagne, which I lately prescribed in a confident 
expectation that it would put a period to her distress. 

I, however, dare very confidently to advise you in all cases of 
obstinate vomiting, connected with pregnancy, to allow your 
patients to drink champagne ad libitum; since, in a great multi- 
tude of examples of the kind, I have found it to procure a perfect 

relief. In the case of Mrs. ■ n, above related, the irritation of 

the stomach had passed evidently into inflammation; and, not- 
withstanding I succeeded, by means of champagne, in appa- 
rently curing the malady of the stomach, you see that the pro- 
vocative cause being still in operation, the disorder returned and 
would not yield to the remedy ; nor would it yield to any other 
remedy which I could employ. You will suppose that I employed 
a great variety of means calculated to relieve the turgescence of 
the vessels of the stomach, both therapeutical and dietetical. But 
all my efforts were vain, for the cause still continued to act. The 
pregnancy was no sooner brought to its conclusion by the birth 
of the child, than all the phenomena disappeared, and as I before 
said, she recovered her health. 

It is a curious fact, that a positive malady of the stomach, one 
which would lead to the supposition that ramollissement of the tis- 
sues had taken place ; one, characterized by such perverse and 
rebellious opposition to treatment, should suddenly yield upon the 
withdrawal of the gestative provocation. 

In the simpler forms of the sympathy of the stomach with the 
growing uterus, when there are acidity, nausea and vomiting, a 
good degree of relief may be obtained by the administration of 
the alkaline mixture, of w T hich I gave the formula a little while 
ago, and which maybe repeated from time to time, say every four 
hours. That particular combination of an alkali with the tincture 
of opium and an aromatic distilled water, is well suited to the 
exigencies of such a condition. It will be proper upon occasion 
to add to the dose five to ten drops of the aromatic spirits of am- 
monia; or to combine it with an infusion of ginger, or the fine 
extract of ginger, prepared by Mr. Frederic Brown, of Philadel- 
phia, a preparation w r hich I am glad to recommend to your notice, 
as being quite equal in all respects, to the celebrated extract of 



486 DISEASES OF PREGNANCY. 

ginger prepared by Oxley of London; an article exceedingly 
useful in many of the gastric affections of pregnancy, as well as 
in some of the digestive maladies of children. 

Many times have I been called upon to give counsel in case of 
morning sickness, as it is called, or the sickness of pregnancy; 
and unwilling, as I always am, to prescribe drugs when I can in 
any way escape such a necessity, and finding that the nausea is 
absent during the night time, while in bed, and that it returns 
upon rising in the morning, I have advised the patient to direct 
the servant to bring to her chamber at an early hour, a cup of 
coffee and her toast; recommending to her to take a preliminary 
breakfast in bed before venturing at all to rise out of the recum- 
bent position, and after taking the breakfast to resume a recum- 
bent posture, which she should not quit for an hour or an hour 
and a half. During this time the gastric digestion is nearly com- 
pleted, and the stomach being fully occupied with, and set upon 
the train of vital actions upon which this gastric digestion de- 
pends, is enabled to resist the morbid sympathies to which, under 
other circumstances, it would infallibly yield. 

Whether the philosophy of the experiment be true or false, the 
fact is very true, as to many instances in my practice. Where 
it fails, you have the consolation to reflect that it has cost nothing 
to the Health of the patient, a consolation you do not enjoy when 
you have cupped and leeched, and blistered and calomelized, and 
teased both her inner and outer man, without having done her the 
least good, and with having done her a great deal of positive 
harm. 

As the morbid sympathy in the nausea and vomiting of preg- 
nancy, must be admitted to take its rise in a qualitative state of the 
uterus, or the reproductive system, it is clear that we shall not 
err in our philosophy, if we suppose that means capable of chang- 
ing this quality of the uterus, may be resorted to for the sub- 
duction of the remote and troublesome symptomatic irritation. It 
is under this view that I have long been in the habit of endeavor- 
ing to subdue what I suppose to be some morbid or morbific con- 
dition of the gestative organ, by obtunding its sensibility by 
using anodyne applications as enemata. The sick stomach of 
pregnancy is in many instances greatly lessened, and in some of 
them, removed, by the use of forty-five drops of laudanum, mixed 



DISEASES OF PREGNANCY. 487 

in an ounce of mucilage or clear starch, as an injection, at bed 
time, and, if necessary, repeated at an early morning hour. 

Riding in a carriage is often found to suspend the sickness of 
gestation. The soluble state of the bowels, maintained by the use 
of enemata, or by any simple aperient medicine, is an important 
part of the treatment ; and benefit has accrued in some of the 
cases, from the use of a tonic infusion, composed of red bark 
and cascarilla, slightly acidulated with sulphuric acid, and 
rendered a little warm by the addition of Huxham's tincture: 
such an infusion, carefully filtered, is by no means disagree- 
able to the taste, and serves to promote the appetite and the 
digestive power. I have tried leeches to the stomach, anodyne 
plasters, sinapisms, aromatic plasters, and a great variety of treat- 
ment, for the cure of the obstinate cases. After having been many 
years engaged in the practice of midwifery, I at this late day 
am obliged to confess that the sick stomach of pregnancy is a 
most intractable malady. I would certainly, had I a case again 
under my care, so distressing as that of Mrs. n, take mea- 
sures to bring on premature labor. I have to condemn myself for 
having permitted her to suffer so long as I did. She was in im- 
minent danger of losing her life ; and her happy recovery at the 
last does not confirm me in the opinion that I was right in allow- 
ing her to suffer so long. 

When the patient has attained the seventh month of her gesta- 
tion, the uterus has risen considerably above the umbilicus, and 
the abdominal parietes are excessively distended in order to make 
room for the distending organ. In proportion as the parietes be- 
come distended, the dimple of the umbilicus will become shal- 
lower and shallower. At the seventh month it has risen to the 
level of the surrounding surface, or forms a protuberance ; and 
as the pregnancy proceeds, it even proceeds so far as to pro- 
duce what is called the pouting of the navel, which is enumerated 
as one of the signs of pregnancy. The umbilicus is concave in 
the non-gravid state, because, when the umbilical cord was cast 
off, six or eight days after the birth of the individual, the remains 
of the umbilical vein and the rest of the two umbilical arteries, 
which, like the umbilical vein, are converted into ligament by their 
condensation or contraction, have drawn the skin about the um- 
bilicus very deeply in toward the peritoneal lining of the abdomen : 
these ligaments have retained it there until the intrusion of the 



488 SIGNS OF PREGNANCY. 

womb has stretched them, so as to allow the umbilicus to pout, as 
it is said. Pouting of the navel is rather the sign of a big belly, 
than the sign of pregnancy ; for, you find pouting of the umbilicus 
in ascites, in encysted dropsy, in chronic tympanitis, and in what- 
ever condition it may be, that may cause the belly to become 
enormously enlarged, so that protrusion of the navel is worth 
something or nothing as a sign of pregnancy. 

Strange modifications of the appetite, or a desire for dry and ab- 
sorbent substances, is a common sign of the state of gestation. 
Some women are fond of eating chalk or magnesia, or charcoal, 
or anything that has an absorbent or alkaline character. This is 
the result of some gastric want, and not perhaps a result of preg- 
nancy; it is one of the accidents of pregnancy, not one of its 
necessary accompaniments. 

Strange desires, called longings, are said to affect pregnant 
women. I have never known any woman affected with longings, 
but they tell very curious stories ; as of a baker's wife, for ex- 
ample, who longed to bite a piece out of her husband's shoulder. 
The value of such signs I leave you to appreciate. 

There is a sign of pregnancy which is of some value. I 
mean the jutting of the hemispherical head of the uterus, above 
the plane of the superior strait, where its presence maybe detected 
by applying the palps of the fingers, while the patient lies upon 
her back with her thighs strongly flexed, so as to relax the ab- 
dominal muscles and integuments. But, such an experiment as 
this could only reveal to you the fact that the hemispherical head 
of the womb is there present, and the inference is strong that 
it is there because the womb is gravid ; but it carries with it no 
demonstration of the existence of pregnancy; and when hereafter 
you should find the uterus thus developed, I put you upon your 
caution not to pronounce your medical opinion upon the cause of 
the development. But, if the hemispherical head of the womb is 
there, and the woman from time to time, perceives certain move- 
ments or impulses in the uterine region, the inference that those 
motions depend upon a living foetus, is a very reasonable one ; but 
still it will not give you authority to pronounce your medical opin- 
ion, forasmuch as you are liable, under such circumstances, to 
be deceived by a uterine tumor, and by a fancied, and not real 
perception of motions on the part of the patient. You may be well 
nigh sure, in your opinion, but you cannot be sure of such 



OBSTETRICAL AUSCULTATION. 489 

opinion. Many a pregnancy has been mi-staken for a tumor, and 
many a tumor for a pregnancy. I have a womb in my collection 
which has the scar of a trocar in it made to relieve a supposed 
dropsy. How could you misapprehend the truth of the diagnosis, 
if you should carefully inquire whether the supposed tumor be 
alternately hard and soft, solid or unresisting ? There is nothing 
could make it so save a muscular contraction. Hence, whenever 
you are at some trouble to decide whether the lump is a tumor or 
a womb, hold your hand on it for a long time — if it hardens and 
softens by turns, it is the womb, and it can be nothing else. 

There are signs of pregnancy which will not mislead you: 
these signs are to be looked for in the double sounds of the 
fcetal heart. It has been said that certain sounds perceived by 
applying the ear either immediately, or mediately through the 
stethoscope, over the uterus, and which are called by the French 
writers bruit de souffle uterin, are reliable ; for it has also been sup- 
posed that these are to be taken as signs of pregnancy. For my 
own part I have not absolute confidence unless these sounds are 
accompanied by the beating of the fcetal heart ; when that is heard, 
absolute knowledge as to the existence of pregnancy is obtained, for 
nothing but a fcetal heart can give the double sound of the heart's 
action. The bruit de souffle uterin may be perceived under 
other circumstances, and therefore is not absolutely to be de- 
pended upon as a sign of gestation. 

There is a work called Traite Theorique et Pratique d 'Aus- 
cultation Obstetricale, par J. A. H. De Paul, of Paris. Paris, 1847: 
8vo. pp. 400. This appears to me to be a very erudite and ac- 
curate work, containing a good exposition of whatever is known 
by the profession upon the subject of obstetric auscultation. 

Dr. De Paul, at p. 243, commences some inquiries as to the 
earliest periods of pregnancy, at which it is possible to perceive 
this beat of the fcetal heart ; and, after giving a statement of nu- 
merous experiments and observations which he had made for de- 
termining the question, he says, at p. 246 : " From the foregoing- 
facts, it appears that the double sounds of the fcetal heart have 
not been perceived earlier than three months and a half, although 
numerous attempts have been made to discover them earlier than 
this period. It further appears, that I have perceived those sounds 
in a much larger proportion of women who had reached the end 
of the sixth month; and finally, that in pregnancy at four months 



490 OBSTETRICAL AUSCULTATION. 

and a half, the absence of these sounds is a very rare excep- 
tion." 

Dr. De Paul says, at p. 247, " I was consulted two years since, 
by a young lady, eighteen years of age, who was married on the 
28th of July, who had always been extremely regular in her 
courses, and had them last on the 18th of the same month, that is 
to say, some days before her marriage. At the end of October, 
[three months,'] when I was called to see her, all the rational signs 
of pregnancy had been for some time in existence. It was easy, 
through the supple and thin abdominal parietes, to feel the uterine 
globe, already jutting above the superior strait. As the lady ma- 
nifested a great repugnance to the vaginal exploration, I was 
obliged to content myself with a stethoscopic examination, w r hich 
I effected with alhthe precautions requisite in such a case. My 
first researches were for a long time without result ; they termi- 
nated, how T ever, in ascertaining the existence of the double pul- 
sations. They w T ere feeble, and difficult to hear ; nevertheless, I 
could count them, and they were repeated one hundred and forty 
times per minute, w T hile the pulse of the mother was scarcely 
eighty. The souffle uterin could not be discovered. Another 
examination, made eight days later, led to a precisely similar re- 
sult, to obtain which I was obliged, as in the first case, strongly 
to depress the abdominal wall towards the pelvic cavity. This 
pregnancy went on regularly, and terminated by a natural labor, 
at the end of the following month of April." Dr. De Paul, at the 
248th page, says, that he "does not understand from this case, 
that the conclusion is established that such a result is always to 
be obtained." He is even inclined to suppose it a fortunate ex- 
ception. 

I am tempted to cite another case from the same interesting 
volume; and, as that volume has not been translated and pub- 
lished in this country, I shall, translate it, and lay it before you. 
The case is as follows : 

" Mad. T , who has already borne several children, had her 

courses from the 10th to the 15th of April. From the 17th to the 
20th of the same month, she cohabited with her husband: he then 
left Paris on a journey, which was to last only a fortnight. Upon 
his return, which w T as early in May, he found his lady confined to 
bed, with the early s}mptoms of a typhoid fever, wrhich, in a few 
days, became perfectly well characterized, and lasted twenty-four 



OBSTETRICAL AUSCULTATION. 491 

or twenty-five days. Her convalescence required a lapse of time 
nearly as long ; and new sexual relations were not established 
until after her recovery. Nevertheless, upon the first of August 
following, as her courses had not reappeared, I was requested to 
see her with a view to determine whether this retention, which was 
very naturally attributed to the severe disease she had lately suf- 
fered, might require the employment of certain remedies for its 
cure. I confess, that I was at first very much inclined to give 
up the idea of a pregnancy begun antecedent to the commence- 
ment of the typhoid fever: I was little inclined to suppose it 
might exist, computing it from the new sexual relations that 
followed her convalescence ; but the examination per vaginam, 
enabling me to detect a notable development of the volume of 
the uterus, I fell back upon the first opinion, of the propriety of 
which I became fully convinced, when, after having applied the 
stethoscope at various times upon the inferior part of the abdomen, 
I discovered the double pulsations, which were repeated one hun- 
dred and forty times a minute, while the pulse of the mother was 
only seventy-six. I could not hear the souffle uterin, 

" Her confinement took place in the following January. The 
child, which was perfectly well developed, appeared not to have 
suffered the least during its gestation." 

Here, then, gentlemen, you have a case in which the double 
sound of the foetal heart was discovered one hundred days, or, three 
months and ten days, after the fecundation had taken place. 
And in which the pregnancy continued two hundred and seventy- 
four days after these foetal sounds were detected by Dr. De Paul ; 
giving two hundred and seventy-four days for the duration of the 
gestation, assuming that the fecundation took place upon the 20th 
of April, and two hundred and seventy-seven days, assuming that 
it took place upon the 17th of the month. It is clear, that in this 
case, it might have taken place on the 17th, 18th, 19th, or 20th. 

With regard to hearing the double sound of the foetal heart in 
auscultation of the uterus, though w r e may feel some surprise at 
the early detection of it in these cases, we cannot refuse to admit 
the exactness of the diagnosis, inasmuch as in both the cases we 
have statements of the rate of the mother's pulse. I examined 
this day, by auscultation, the uterine region of a young lady sup- 
posed to be three months gone with child; she has been very 
much reduced by a severe attack of the vomiting of pregnancy, 



492 OBSTETRICAL AUSCULTATION. 

accompanied with a hectical state of the circulation. There is 
nowhere to be discovered the least sign of the bruit de souffle ; 
but a rapid double sound, coinciding with the double sounds of the 
heart, is heard whenever the ear is placed over the uterus ; but 
these double sounds are those of the maternal heart, and not of 
the foetal heart, for they are perfectly coincident with her pulsa- 
tions, — but for this coincidence the diagnostic would be erroneous. 

I relate these cases as encouraging you to hope to be able, in the 
course of your practice, to discover these proofs of pregnancy as 
early as they have been detected by Dr. De Paul ; yet I beg you 
to believe, that such an early discovery is more likely to be owing 
to a fortunate accident, than to any general facility to be met with, 
and on which you might rely for the expectation of being able to 
make so early a detection. 

Dr. Evory Kennedy, author of Observations on Obstetrical Aus- 
cultation, etc., Dublin, 1833, lately Master of the Dublin Lying- 
in Hospital, says, at page 101 of his work: "Although we have, 
in a few cases, detected this sound even before the end of the 
fourth month, it will not, in the majority, be possible until a later 
period, and in those cases w T here it can be detected about this 
time, it is sometimes so delicate and feeble, as to render it neces- 
sary for the individual exploring, to have an ear well trained to 
stethoscopic sounds. In general, therefore, we look upon this 
phenomenon as not to be detected until after the period of quick- 
ening, when the uterus has risen out of the pelvis, and allows of 
our coming more immediately in contact with the part of it in 
which the embryo is contained." 

Such is the opinion of one of the most practised obstetrical aus- 
cultators now living. I beg you to remember this opinion, ex- 
pressed by Dr. Kennedy, so that, when you come to make this 
obstetrical auscultation, you may feel no embarrassment, and ex- 
hibit none when you fail to detect the sound in those stages of ges- 
tation in which the sound cannot possibly be perceived. When 
the child has acquired a degree of development, sufficient, not only 
to render its motions perceptible to the mother, but sufficient 
also to render the sounds of its heart audible in auscultation, there 
is little difficulty ; and the greater the progress of the pregnancy, 
the louder and more distinct the sounds ; so, that from the sixth 
month, to the conclusion of the full term, you will have just rea- 
son to expect to discover these sounds, where they really exist; 



OBSTETRICAL AUSCULTATION. 493 

and not only to discover the sounds of the foetal heart in cases of 
single pregnancy, but those of two distinct hearts in cases of 
twins, the sounds being heard in different regions of the uterine 
globe. 

I was going to say, that I implore you never to pronounce de- 
finitively upon the existence of a pregnancy, unless you can clearly 
make out the sound of the foetal heart; or unless you can touch 
some part of the foetus in a vaginal examination; for you may be 
deceived by supposed motions, supposed resistances, supposed 
dimensions and forms, ascertained through the abdominal pa- 
rietes. The two preceding methods on which I recommend you 
to rely can never deceive you. How desirable is it that a physi- 
cian shall not suffer himself to give an erroneous opinion. I as- 
sure you, that I think nothing could tempt me to give an opinion, 
except from one of the two signs above mentioned. I may be 
ready to admit the extreme probability of the existence of a ges- 
tation ; I may not dissent from the opinion of the patient herself; 
but for my part, I will not pronounce until I shall know. This 
unalterable resolution has conducted me safely through many diffi- 
culties, nor has it ever exposed me, as far as I know, to the least 
inconvenience or danger. 

The obstetrical auscultation, as it is called, was really disco- 
vered by the distinguished physician, Maior, of Geneva, though 
the credit of it is generally given to M. de Kergaradec. M. de 
Kergaradec read his communication upon the subject at the Royal 
Academy of Medicine, on the 26th of December, 1821, since 
which time great progress has been made as regards the pre- 
cision of the results to be obtained by this method of diagnosis. 

While I am treating on this subject, it may be as well to say, 
that the obstetrical auscultation of the foetal heart is highly useful 
to determine questions as to the life or death of the foetus inutero, 
as well as questions relating to its health and safety, and the ne- 
cessity of doing, or forbearing to do, certain things in the conduct 
of a labor, as necessary for the conservation of the life of the 
child. 

The same art of obstetrical auscultation may be most usefully 
applied for the purpose of ascertaining the presentation of the 
foetus; the extremity of the stethoscope being placed in the situa- 
tion the nearest possible to the beating heart, will determine the 



494 OBSTETRICAL AUSCULTATION. 

place of the heart; which, being nearer the os uteri or the fundus 
uteri, will determine the presentation. 

I am not writing a treatise upon midwifery, but I can very 
readily conceive, that the general practitioner who undertakes to 
treat the diseases of females, irrespective of their lying-in manage- 
ment, might have frequent occasion to examine the health con- 
dition, and the presentation of the foetus in utero; wherefore, I 
have proffered you these remarks. 

There is a sound to be discovered by obstetrical auscul- 
tation, which is called the placental souffle, the uterine souffle, 
and the bruit de souffle uterin, as Dr. De Paul prefers it should be 
called. This is a sound which you hear with your stethoscope, 
or ear, applied over the globe of the uterus, in pregnant women. 
That is to say, it is a sound that is heard, provided the ear or the 
stethoscope be applied upon that part of the uterine globe imme- 
diately under which the cause of the sound exists ; for it does not 
exist in all parts of the uterus, being mostly to be heard upon the 
sides, and also in the immediate vicinity of the placental attach- 
ment. 

It is a blowing sound, and it often sounds like the rush of air 
issuing from the nozzle of a bellows, when one is blowing the fire. 
Sometimes it is musical, and resembles very nearly the note of a 
dove cooing at some distance from the ear. It is in some instances 
like a faint breathing, and in others like a loud snore. It is un- 
attended with any shock or suddenness. While you listen to it, 
and hear it with the utmost distinctness, it often ceases to be 
heard, and then recommences, although, in the meantime, you have 
not removed the stethoscope from the spot where you heard it, and 
where you have continued to listen. It is probably owing to the 
motion of the blood in its vessels, and is attributable to the escape 
of the blood from a narrower into a wider channel. For exam- 
ple, if the posterior lateral surface of the uterus should press hea- 
vily upon the primitive iliac, the external iliac, or the internal iliac 
vessels, so as to lessen, at the point of contact, the calibre of the 
tube, the fluid issuing into the uncompressed portion, would pro- 
bably occasion the sound of the placental souffle ; just as the blood, 
issuing from the cylindrical portion of an artery, into an aneuris- 
mal dilatation of the same tube, gives out the aneurismal sound. 

Some authors have supposed that the sound is occasioned by 
the rush of blood into the great sinuses and veins of the uterus ; 



PLACENTAL SOUFFLE. 495 

that it is occasioned by the rush of blood from the veins of the 
uterus, into the so called cells of the placenta ; and a variety of 
explanations, that have been offered for it ; but nothing appears to 
me more clear than the one which I have presented to you above. 

Dr. De Paul, whom I am willing to take as authority upon this 
point, thinks it is probable that the bruit de souffle exists for 
some time before it can be distinguished. I will allow myself 
in the criticism, that it would be better to say, that the causes of 
the bruit de souffle exist earlier than the bruit de souffle itself; 
for a sound that cannot be heard, is not a sound. 

M. Kergaradec mentions a case, at page 276, in which he 
heard the bruit de souffle on the eightieth day. 

M. Orfila refuses to regard this sound as a certain sign of 
pregnancy. 

Dr. De Paul, at p. 206, says, " For my part, I do not hesitate 
to make the declaration, that the uterine souffle is not a certain 
sign of pregnancy." M. Jacquemier, of Paris, and M. Stoltz, 
of Strasburg, do not regard the bruit de souffle as a sign of preg- 
nancy. 

You will find, in the course of your surgical studies, that tumors 
in the abdomen, from their pressure upon the great vessels, 
produce sounds not to be distinguished from the bruit de souffle 
uterin ; and it is not to be doubted that the empty uterus, after 
labor, in many cases, yields the same sound. Now if this repre- 
sentation be just and true, and I believe it to be so, what real 
value will you attach to the discovery of this sound in any case of 
obstetric auscultation ? It can have none at all, since it clearly 
proves neither the existence of the child, its life, nor its death. 
With these remarks, I shall trouble you no further with the pla- 
cental souffle. 

As pregnancy advances, the uterus becomes constantly aug- 
mented in size. In the primiparous woman, in whom the abdominal 
muscles and tegumentary tissues have never before been weak- 
ened by the distension attending the gravid condition, the globe of 
the uterus is strongly resisted in its ascent into the abdomen. 
This resistance presses it against the firm solid back part of the 
cavity. For the most part, the uterus is in a flaccid condition, grow- 
ing hourly, daily, weekly, larger under the compulsion exercised 
by the developing ovum ; yet, it is true, that from the beginning of 
pregnancy to its end, the contractility of the uterus is frequently 



496 DISEASES OF PREGNANCY. 

exerted in such a manner as to condense and harden its fleshy 
textures. When so condensed, the hand applied on the exterior 
of the abdomen, meets with a firm, solid ball, incompressible 
during the contraction, its outline clearly definable by pass- 
ing the finger over it, but disappearing after from ten to thirty 
seconds, upon a restoration of the flaccidity of the tissue. When 
the uterus is thoroughly flaccid, it is impossible to define its out- 
line through the integuments, the whole belly presenting the ap- 
pearance of a uniform, soft, compressible, fluctuating tumor. 

During the oft-repeated contraction of the uterus, and probably, 
also, while it is not in such a state of condensation, the organ 
presses more or less heavily against the arteries and veins, as well 
as the absorbent branches in the lumbar region, and also upon the 
sides of the pelvis, just above the brim. This compression of the 
absorbents, and of the veins, interrupts the free course of the 
lymph, and the venous blood, in their ascent towards the upper 
parts of the body. A strong pressure could not fail, in like man- 
ner, to contravene the freedom of the flow of blood, in its down- 
ward course, through the arteries ; for the pressure of the uterus 
produces the effect of the pressure of a tourniquet-pad, though in 
a very slight degree. 

The interruption to the ascent of the lymph, and the detention 
of the blood, is necessarily followed, at first, by an increase of the 
halitus in the cells of the cellular tela, from some diminution in the 
power of the absorbents, which should carry it away; hence, by slow 
degrees, there is formed a collection of serous fluid in the cellular 
tissue of the knver extremities, which is manifested by an increase 
in the size of the ankle and foot, and which gives the lady a dis- 
position to go about slip-shod, or to take a larger pair of shoes. 
As the swelling increases, it becomes cedema ; if the cause con- 
tinue to act with a certain degree of intensity, the cellular tissue 
of the legs and thighs becomes thoroughly distended with fluid, 
which pits upon pressure, is incommodious from its weight, and 
not unfrequently painful from its distension. If the action of the 
absorbents is still more greatly contravened by the pressure of 
the uterus, the amount of the halitus produced will be pari passu 
increased, and, as the infiltration goes on, the fluid in the upper part 
of the thigh passes into the cellular tela on the trunk of the body, 
where it infiltrates everything; it rises to the throat, which is 
enormously distended ; it fills the arms, and bloats the face ; so 



DISORDERS OF PREGNANCY. 497 

that the woman is, at last, afflicted with an enormous anasarca, 
which is the result of no disease, but is dependent simply upon 
the accidental interruption to the action of the absorbent trunks in 
the lower extremity. It is probable, that you will meet with some 
cases of this kind, which will fill you with surprise on account of 
the enormous amount of infiltration. 

As I have already spoken upon the subject of infiltration in my 
fifth letter, I do not deem it necessary to enter here into any conside- 
rable discussion on the subject ; my principal design and desire in 
the present mention of the topic being to make you clearly under- 
stand that there is a great difference between an anasarca arising 
from a morbid condition of the constitution, and an anasarca more 
properly to be denominated oedema gravidarum, or infiltration, 
which, taking its commencement in the lower extremities, depends 
solely upon the pressure of the gravid uterus upon vessels, and 
vanishes like snow before the sun, as soon as the pressure is 
taken off. It vanishes, I say, like snow before the sun, sometimes 
under greatly augmented discharges from the kidneys, and some- 
times without any perceptibly increased diuresis. A great diure- 
sis would not be necessary, provided the cause of its production 
were entirely withdrawn ; for the production having entirely sur- 
ceased, the power of elimination exercised at the ordinary rate, 
might be expected soon to remove every excess. It is hardly 
worth your while, under these views, to trouble your patient, and 
compromise the health of her stomach and bowels by the admin- 
istration of drugs ; for she is not sick, nor will your drugs have 
any other effect than to make her sick. She does not want a 
drug ; she only requires that the pressure of the uterus should be 
taken off. 

Pregnant women have a great tendency to become constipated, 
and to overload the colon with unknown and unsuspected accumu- 
lations of stercoraceous matter. Such accumulations add to the 
power of the pressure already too great, and common sense dic- 
tates that they should be obviated or removed. Let the woman 
keep her bowels in a soluble state: give her two or three rhubarb 
pills twice or three times a week ; but this is not so good 
treatment as to let her take a couple of Lady Webster's pills imme- 
diately after her dinner, when her stomach is full of food ; which 
is preferable to the use of rhubarb pills. 

But this is physic, and you can give her a pleasanter remedy 
32 



498 DISORDERS OF PREGNANCY. 

than this. Let her infuse half an ounce of senna in a pint of 
boiling water for two hours ; let her strain the liquor over a pound 
of prunes in a saucepan, adding to the mixture a handful of loaf 
sugar ; let the prunes stew until they become well cooked, soft, 
and pulpy, after which, they may be poured into a bowl or 
jar for use. Now, a prune cooked in this way tastes as plea- 
santly as if it had been cooked in spring water; it will amuse her 
to eat six or eight of them per diem ; they will keep her bowels 
open without griping or purging, and assist very materially in ob- 
viating the tendency to an increase of her oedema gravidarum. 

I have no doubt that in case of pressure exercised by the womb, 
the veins and absorbents being the weaker vessels, suffer a greater 
degree of compression than the artery, which is endowed with 
an elastic coat, along the tube of which the blood is impelled by 
the energy of the heart's contraction ; the blood of the femoral 
vessels, and of the popliteal, may reach their distal extremities 
with a momentum so great, that, favored by the diminished power 
of the veins, and the absorbents, it rapidly increases the effusion 
and the infiltration. Hence, where a primiparous woman has 
cause to complain of the infiltration of the lower extremities, 
and the arterial pulse exhibits a strength and momentum above 
the par of healthy action, it is highly reasonable, and sensibly con- 
ducive to her comfort and safety, to lessen the force of the blood's 
motion by bleeding a vein in the arm ; and this offers you an in- 
telligible rationale of the common method, which is to bleed a 
woman whose legs are too much swollen. 

I repeat that I am not writing a treatise upon midwifery ; and that 
though you may not be obstetricians, yet, as physicians, you will 
often have charge of the health of pregnant women. 

You have just considered the effect of pressure upon the blood 
returning from the extremities ; I pray you now to ponder upon 
the effect which the same pressure would have in diminishing 
the flow of blood in the arteries below the bifurcation of the 
aorta, and the inevitable polygsemia of the upper parts of the 
trunk and the members, coincident with such diminished flow 
downwards. 

If your patient, in an advanced stage of pregnancy, wakes in 
the morning with her face bloated, her hands and wrists so swollen 
that she can with difficulty flex or extend the fingers ; and this ac- 
companied with pricking sensations affecting the arm, as though 



DISORDERS OF PREGNANCY. 499 

the member had been asleep ; with sickness, pain in the head, or 
vertigo; you would at once refer such phenomena to their true 
cause, which is the polygamic state of the upper part of the trunk 
and limbs. In the progress of the day, as she sits up and moves 
about upon her feet, the polygsemia ceases, to return upon taking 
the horizontal posture, and to manifest itself again on the following 
morning, and so on from day to day. Such a woman ought to 
be bled, because, if this hypereemic condition be allowed to be 
renewed from day to day, for weeks in succession, the vessels of 
the brain w T ill become habitually surcharged, exposing her to no 
little risk of apoplexy during her pregnancy, and greatly aggra- 
vating her liability to eclampsia when, to an habitual hyperemia, 
she comes to superadd the dangerous congestion which coincides 
with a first, hard, long, laborious labor. I shall now dismiss 
the subject of oedema gravidarum, satisfied that I have laid before 
you all the explanations relative to it which seem to be ne- 
cessary. 

The duration of a human pregnancy may be stated at two hun- 
dred and eighty days, and if you have occasion to calculate for 
your patient the probability as to the period of her confine- 
ment, you should inquire as to the date of the disappearance 
of her last menstrua. It is most probable that when fecundation 
takes place, it will take place soon after the disparition, within 
from one to four or five days ; more likely on the first than on the 
fifth. The Jewish women, as I mentioned in a former letter, do 
not return to the husband's bed until eight days after the dispari- 
tion, and yet they conceive and bear children, which is a proof 
that the deposited ovulum still preserves its vitality at that late 
period, and possibly as late as the twelfth or thirteenth day; so 
that a Jewish woman, who is going to make her computation for 
two hundred and eighty days, would begin on the ninth day 
after her last menstruation. Some persons do always allow eight 
days to elapse before they commence the computation, and then 
add two hundred and eighty. But for more than thirty years that 
I have been in the habit of making the computation, commencing 
from immediately after the recovery, and allowing two hundred 
and eighty days, I have had no reason to change the method. 

The same causes which produce the distressing infiltrations of 
which I have been treating, act on multitudes of women with such 
intensity, as to establish for life a varicose condition of the veins 



500 DISORDERS OF PREGNANCY. 

of the lower extremities. I don't think that you will meet with 
a great many women who have repeatedly gone through the uterine 
gestation, in whom some of the veins of the lower limbs have not 
become permanently varicose ; that is to say, enlarged, distended, 
tortuous, causing the appearance of dark venous stains on the 
tractus of the vessels. While not pregnant, and not sustaining 
the weight and pressure of the womb upon the vessels within the 
pelvis, these varices, although they exist, are not always trouble- 
some ; but upon the re-establishment of the state of gestation, 
the interruption of the flow of blood exists to such a degree as to 
render them highly inconvenient and painful. 

In proportion as a female approaches the term of her gestation, 
such a condition of the veins of her extremities becomes hourly 
more worthy of regard and attention ; for it is dangerous in the 
extreme, to allow the disorder to go beyond a certain limit, the 
overpassing of which exposes the vessels to attacks of inflam- 
mation, which constitute phlebitis. I have seen a sample of 
frightful phlebitis supervening upon an unregarded varicose state 
of these vessels in a pregnant woman, and which resulted in her 
death from a pyogenic fever, taking its origin evidently from the 
points which I have just indicated. If there be in such a woman 
a condition warranting you to let blood, you ought to do so in ful- 
filment of a clear indication. Such a woman should be consci- 
entiously instructed and warned against the danger to which she 
w T ould be exposed by being long in a standing position, and she 
should be earnestly advised to observe a recumbent posture, not 
only during the night, but frequently during the day time, with a 
view to allow the distension of the vessels to have some inter- 
mission. 

Inasmuch as, under these circumstances, the texture of the 
vein may be considered to have lost its tone, its contractility, its 
power of resisting the lateral pressure of the blood column, you 
ought sedulously to provide some succedaneum for the lost tone, 
which you can only find in what the surgeons call position, or in 
the use of a laced stocking, gaiter, or bandage ; by either of which 
methods, the dangerous distension of the tube is prevented, and 
the patient safely conducted to the term of her accouchement ; when 
the pressure being taken off, she will no longer be subject to the 
varix gravidas. 

I shall close this letter here, with the expression of my sincere 
respect. C. D. M. 



DISORDERS OF PREGNANCY. 501 



LETTER XXXVIII. 

Gentlemen: — There are not a few persons, who, in the preg- 
nant state, become affected with seeming diseases of the heart, 
characterized by irregular action of that organ, such as palpita- 
tion, great augmentation of the superficies of pulsation, dyspnoea, 
orthopncea, paleness, convulsions, sudden loss of sight and hear- 
ing, followed in the long run by oedema and true anasarca. I am 
speaking of persons who seem to labor under disease of the heart, 
and I speak, having in my mind a vivid recollection of divers 
cases that I have had the charge of in the course of my practice. 

A pregnant woman ought to pass through the whole of her 
gestation without any feeling of disease ; and many women do, 
in fact, conceive, develop, and bear their children without any 
apparent change of their health or comfort. I have seen young 
women not far from term, skip up and down stairs as if they had 
not been married, preserving all their activity, agility, and appe- 
tite, their good spirits, their color, and their temperature, enjoying 
food, sleeping, and waking, as if nothing was the matter with them. 
But there are some constitutions on which the influence of preg- 
nancy is disastrous in the extreme, constitutions in which the ges- 
tation seems to be a direful effort of the life forces that they can 
scarcely carry out, which they are often unable to perfect, and 
which, in some instances, is perfected at the expense of the wo- 
man's health and life. 

A woman who develops her child requires an augmentation 
of her hsematosic power; indeed, it is but fair to say that she 
requires an augmentation of the hoematosic power for the uses of 
her own constitution, applying it to the maintenance of her own 
developments, which demand considerable reinforcements when 
the life force is exerted with a preternatural energy. The reaper 
in a harvest field requires more drink and more food than the idler; 
the woman who maintains not only her own development, but also 
furnishes the materials for the development of the child, may in 
respect to her wants be compared to the reaper in the harvest field. 



502 DISORDERS OF PREGNANCY. 

But, an augmented development power is a power augmented at 
the expense of th.e nervous constitution or matter. There are 
some nervous constitutions that can furnish it without detriment, 
whereas others sutler the greatest detriment in doing so. 

If the nervous system becomes affected by these efforts, it may 
show the affection in some diminution of its power, and the dimi- 
nution of its power will be most likely to manifest itself as to the 
specific tissues, that are most immediately subservient to the super- 
erogatory demands of the occasion. Inasmuch as all development 
takes place at the expense of the blood, of which the consump- 
tion and loss are very great in gestation, it is not, I think, unphi- 
losophical to suppose, that the specific tissue most likely to suffer 
under these circumstances, is the tissue which in former letters I 
have repeatedly mentioned under the title of the endangium, of 
Mr. Burdach, or blood-membrane, as I prefer to call it. But, if 
the blood-membrane, in consequence of exertion of its faculties, 
becomes weakened, becomes diminished as to functional force, 
then we shall have an imperfect blood, imperfect in regard to the 
proportion of its solid constituents, which are diminished while 
the watery part is abnormally increased, which would constitute 
a state of anaemia. But a condition of anaemia in a constitution 
bound to carry on the great operations of gestation, is one likely 
to be attended with faulty innervation; faulty innervation, not 
only of the cerebellar and cerebral and spinal nerves, but of the 
whole ganglionic system of nervous supply. 

The patient will become emaciated more or less, while her 
cellular tissue is infiltrated with serum or halitus, giving her the 
appearance of an embonpoint which is likely to deceive the in- 
cautious diagnosticator. The increased proportion of water in her 
blood will give to her superficies a character of pallor or chlorosis, 
and the diminution of the universal tone will extend even to the 
heart itself, which may become so flabby as apparently to increase 
in magnitude and give rise to a great increase of its pulsative 
superficies on auscultation, misleading the inquirer, and causing 
him to believe in the existence of a disease of the heart, whereas 
the disease is essentially an anaemia, or an endangial malady only. 
These are most distressing cases ; they generally become aggra- 
vated in proportion to the advance of the pregnancy ; and not 
unfrequ ently admit of such extensive dropsical infiltrations, not 
only of the cellular tissues, but even of the serous cavities, 



DISORDERS OF PREGNANCY. 503 

particularly the thorax, as to bring the patient's life into the 
extremest peril. Yet these maladies are not diseases of the heart ; 
they are samples of anaemia, from which, often, the patient reco- 
vers with surprising rapidity, when the cause — videlicet, the ges- 
tation — has been brought to its term by the birth of the child. 

In cases of organic disease of the heart, I mean vast dilatation 
of its cavities, there is no reason to expect a rapid recovery, or 
perhaps a recovery under any circumstances. But the ansemical 
dilatation, or, if you permit me to use the term, the ansemical laxity 
of the heart's fibre, might well, and in fact does, for the most part, 
disappear under an appropriate treatment, when its provoking 
cause, to wit, the anaemia, has been removed. I am very desirous 
that you should give attention to this theory of the case, and that 
you should endeavor, whenever you shall come to take charge of 
a pregnant woman, affected with disease of the heart, to make a 
careful discrimination between the incurable organic lesions of 
that important organ, and the modifications of its density and con- 
tractility, that may be superinduced by a too feeble innervation of 
its tissues. 

The most extravagant deviations in the heart's action that can. 
be produced by the ansemical state, are for the most part found to 
be lessened and even to disappear wholly, when the patient is 
placed in a recumbent posture, and has had time enough to 
allow the accidental hurry and excitement which have been pro- 
duced by exertion, motion, or emotion, to subside, and the rate of 
all the functional forces to come down to a condition conformable 
to the wants of the economy in a state of profound repose. The 
ansemical disorder, under a supposed condition of perfect repose, 
disappears in so far, at least, as it can be manifested by the re- 
spiration or by the circulation. This is not the case in the true 
organic disease of the heart, where, though the derangements of 
the heart's action, aggravated by exertion, are frightful, indeed, 
yet they do not wholly disappear even in a state of the most 
profound repose, but leave their physical signs so plainly dis- 
cernible to the practised inquirer, that he cannot be misled by 
them. The hypertrophic throb of a thickened ventricle, and the 
feeble imperfect action of a coincidently dilated auricle, can be 
detected by the ear, even after a long night's repose. But the 
irregular, disordered, anomalous, feeble beat of the anaemic heart, 



504 DISORDERS OF PREGNANCY. 

give place to a perfect rhythm, impulse, and superficies, after such 
a repose has been had. 

I am very desirous that you should make a careful discrimina- 
tion in the cases supposed, and that you should not mistake the 
quick but feeble impulse of the ansemical heart, for the stern, re- 
solute and dangerous injective force of the hypertrophied ventricle. 
In the one, you will be prompted to use the lancet as a means 
of diminishing the excessive general momentum of the arterial 
pulse; in the other, you would prescribe profound recumbent rest 
to save the constitution from the effects of the disordered and 
convulsive beat which follows every effort. You would direct a 
nutritious and light diet, you would give wine and iron, you would 
direct well ventilated rooms, you would prescribe the use of mo- 
derate anodynes and antispasmodics, to obtund the exaggerated 
sensibilities of a debilitated constitution ; and in so doing, you 
would conduct the patient wisely, if not safely, to the term of her 
utero-gestation, which, being completed, and the cause being 
removed, leave you afterwards nothing to do, but contend against 
the pathological causes of the simplest anaemia. 

But I have already said so much in these letters upon that 
subject, that I shall not offer any further observations here, and 
I refer you to those letters, in the confident belief, that the 
pathological principles there explained, are founded in sober 
views of important truths. 

In the treatment of these ansemical cases, you will meet with 
prejudices against the employment of ferruginous articles; for the 
public in general, who believe that iron is endowed with what are 
called forcing properties, as regards the menstrua, are timorous 
as to the use of such therapeutical agents during gestation. They 
suppose that forcing articles have the power to produce abortion 
or premature labor, because they thoroughly believe that such 
forcing articles are capable of bringing on menstruation, in season 
or out of season. To you who have adopted the doctrines of the 
periodical ovulation and deposit, I need not say, that the chaly- 
beates have no such forcing power as is supposed, and that the 
use of them during gestation is not less prudent and safe, than 
that of any other tonic medicine whatever, and I have not the 
least misgiving as to the propriety and safety of employing them 
for the cure of these endangial maladies in women pregnant, 
whether in the early or in the advanced stages of gestation. 



DISORDERS OF PREGNANCY. 505 

I attended here a few years since, a young woman during the 
latter half of her utero-gestation, and during the labor in which it 
terminated ; a case which w T as put in my hands by the advice of 
her medical attendant, on the ground that it was a very dangerous 
one, with which he was not disposed to charge himself. 

She presented all the appearances of great dilatation of both 
the auricles and ventricles of the heart — the impulse of which 
was perceptible to the right of the middle of the sternum. The 
pulse, except when she was in a state of recumbent rest, was 
large, gaseous, unsteady and very sudden. The face and whole 
surface were pale and flabby, the cornea nearly uncovered of the 
upper palpebra. The respiration was troubled, and on the least 
motion or emotion, precipitate and difficult. At the end of the 
seventh month, the lower limbs became considerably infiltrated, 
and the power of muscular motion much curtailed in consequence 
of its being always attended with violent beating of the heart, 
breathlessness, and uneasy sensations in the head, as pain, ver- 
tigo, noises and dimness of sight. 

The progress of the pregnancy was accompanied with aggra- 
vation of all these appearances. 

On different occasions she had attempted to w T alk in her house, 
and had fallen on the floor in a state of insensibility. I, being 
hurriedly notified of such an accident, arrived on one of the 
occasions, at the house, soon after she was taken up from the floor 
and laid upon the bed. 

I found her absolutely pale, scarcely able to speak, and com- 
pletely blind when I arrived. She knew my voice, and opened 
her eyes to look at me as I spoke : — the eyes were bright, the pu- 
pils natural, but she was wholly without sight. She complained 
of some degree of fulness of the head. The pulse was still agi- 
tated. In a short time the sight returned and was perfect as 
before. I do not recollect how many times she actually fell in 
this manner, and with such following phenomena, but the accident 
was repeated several times. In nearing the term, the swelling of 
the limbs from oedema was greatly augmented, so as to affect the 
thighs, and the buttocks, and labia; the pericardium became also 
the seat of a dropsical effusion, so that a complete orthopncra soon 
declared itself. 

My patient could not lie down day nor night. If she sat up 
with a pillow against her back and shoulders, the oppression be- 



506 DISORDERS OF PREGNANCY. 

came so dreadful, she was obliged to throw them away; but, 
requiring some support, she placed her back against one of the posts 
at the foot of the bed : leaning on the slender cylindrical bed-post, 
she could find the needful support or rest without the oppression 
brought on by pillows or cushions. Here she sat day and night for 
many days, with very bad thin blood, which was imperfectly oxy- 
genated, and so, greatly increased the disorders of the innervation. 
Her condition was truly deplorable, and it was difficult to imagine 
that the heart could^ever recover its form, consistency and power, 
should she even escape death in the impending conflict of labor. 
In fine, labor came on, and in due time I delivered her with the 
forceps in order to save her from the necessity of exerting any 
voluntary force. 

Soon after the birth of the child, she began to sleep upon 
pillows, which she allowed to be made up lower and lower; and, 
at the end of the month of her lying-in, it was no longer a ques- 
tion whether she would recover her health. Her health soon 
became stronger, and now she is in consummate health. The 
heart presents no evidences of disease whatever. 

I look upon it that all the distress and the peril of this young 
woman proceeded originally from an endangial malady, provoked 
into exaggeration by the demands of the gestative state on the 
blood-membrane. The whole scene was a scene of the effects 
and complications of a simple anaemia. Anaemical girls — girls 
who have passed badly through their puberic age and crisis — are 
more liable to be affected as in the manner above described, than 
others, if they subsequently to marriage become the victims of 
pregnancy. 

Women in pregnancy are liable to palpitation of the heart, 
especially dependent on ansemia. 

I advise you, whenever you encounter the case of a pregnant 
woman who complains to you of sudden attacks of palpitation of 
the heart, to inquire carefully into the causes of such palpitations; 
more especially is it your duty to do so, where the attacks of pal- 
pitation continue for a considerable length of time before the heart 
recovers its usual rhythm. A woman who, in her gestation, has 
an attack of palpitation which lasts her from two to six hours, is 
absolutely in need of good advice; for, notwithstanding I have 
seen cases of palpitation lasting from morning to night, and 
attended with the most distressing sensations, and the most com- 



DISORDERS OF PREGNANCY. 507 

plete disability of all the organs of relation ; the patient, upon 
recovering the normal rhythm of the heart, seemed to be from 
that moment perfectly well, save a feeling of debility, and per- 
haps some pain in the extremities, which, however, soon vanished 
by the aid of a little rest. I have seen the heart beating 
more than two hundred and twenty times a minute for ten con- 
secutive hours, and yet the patient who had been in such an ap- 
parently dangerous situation, has evinced no considerable signs 
of disorder a short time after the cessation of the palpitation. 

I confess to you, gentlemen, that notwithstanding the frequent 
examples of perfect recovery from such extravagant palpitations, 
I can with difficulty imagine that the individual can be safe 
during the existence of them ; for the blood must reach the organs 
with a pressure, and with a momentum so different from those 
that attend a healthful state of the circulation, that the development 
force, one would think, could not fail to produce organic lesions 
in some of them. 

But these irregular actions of the heart do, in fact, in some of these 
cases, give rise to organic changes, and the heart itself, which is 
the first organ served by the systemic circulation through its 
coronary vessels, is the one perhaps most likely to suffer. In- 
deed, it often does suffer, and through its own illness and imper- 
fect functional power, gives rise to a patible state of the brain, 
which, in consequence thereof, determines imperfectly its inner- 
vations to the organisms, and so the whole constitution is over- 
thrown and made a wreck. 

What will you do with these palpitations, supposing that they 
are the result of pure anaemia? Here I pray you to take into con- 
sideration the case that I proposed in a former letter, of persons 
breathing at a vast elevation on the side or summit of a mountain, 
where the pressure of the mercury in the barometer allows the 
column to stand as low as sixteen or eighteen inches, not for 
want of a given number of cubic inches of atmospheric air, but 
for want of a given number of cubic inches of atmospheric air of 
a certain density. Such persons, you may remember, are per- 
fectly at ease while sitting down upon the snow, or on a projecting 
point of rock ; their pulses beating naturally, and their respiratory 
act being performed without any notable exaggeration; but, as 
soon as they begin to move, and call upon their mnervative 
powers for extraordinary dotations of nerve force, the heart beats 



508 DISORDERS OF PREGNANCY. 

violently and irregularly, the diaphragm and respiratory muscles 
make the most violent efforts to carry on the respiration in the 
lungs ; the head aches and becomes dizzy, and the traveler, after 
taking some twenty paces, is obliged to stop, and give rest to his 
respiratory and circulatory organs, in order that they may recover 
their composure, and have time for the generation of an amount 
of nerve force conformable to the wants of the next succeeding 
efforts in ascending. 

Now, your ansemical patient, as I stated in the letter alluded 
to, is in precisely the same condition as to the oxygenating power, 
as the traveler on the top of Mont Blanc or the Yungfrau, and, if 
you permit her to continue to take exercise, or advise or compel 
her to do so, you act as unwisely as M. De Saussure would have 
done, had he insisted upon the members of his party continuing 
to make continued efforts to ascend, instead of allowing them to 
rest and recover their powers of innervation. 

Continued exertion in an atmosphere so rare as that w T hich is 
found in the highest altitude of mountains, is, perhaps, impos- 
sible ; but if it w^ere possible to urge the traveler onward wuthout 
rest, he would doubtless perish from apoplexy of the head, the 
lungs, or some other apoplectic tissue. 

If your patient, then, continues to labor or to exercise under 
these conditions, there is great reason to fear that some of the 
important organs will be compelled utterly to give way; whereas, 
if you treat the case wisely, there is little danger of any of the 
organs giving way, and your patient w T ill go on to the full time of 
her pregnancy, experiencing, perhaps, occasional attacks of palpi- 
tation, but recovering from them well, and fitted to meet at last 
the conflict of labor without risk, and without much suffering. 

When I meet with a case of extraordinary palpitation from an 
anaemic cause, I feel that I shall not cure my patient, until I cure 
her by means of a trained exercise. I shall expect my patient 
daily to walk many miles, before her health shall be completely 
established, but I do not allow her to begin the process of training, 
until first, by a long rest, sometimes by a rest of a week or more 
in bed, I have prevented her from experiencing the abnormal 
innervation of , the heart, which every imprudent or excessive 
attempt at exertion had not failed before to bring upon her. 

During this preliminary rest, I take advantage of the occasion 
to prepare her for the training treatment, by getting the skin into 



DISORDERS OF PREGNANCY. 509 

a favorable attitude, by procuring determination to the surface 
favoring the operation of all the secretory organs, invigorating a 
little their tonicity by nutritious diet, by cordials and by tonics ; 
and then, when I begin to allow her to take exercise, I direct her to 
adjust the amount to her ability, increasing a little by little, until 
I carry it up to the desired point. 

If such a caution be necessary in the conduct of the cases of 
palpitation, even in the anaemia of the virgin, how much more 
desirable is it, that it should be applied to the cases of pregnant 
women ; since the sequelse of the palpitation are so distressing 
whenever there are superadded to them the constitutional excite- 
ment and the disturbance that must attend upon a violent or a 
protracted labor. 

I find, that, notwithstanding my intention in a former part of 
this letter, to trouble you no more with observations on the sub- 
ject of anaemia, I have not been able to overcome the disposi- 
tion I felt to give the above explanation. But I hope you will 
consider the explanation now T , for the necessity of rest is as ap- 
plicable to the cases of palpitation derived from the thickening of 
the valves, from their laxity, from their granulation, from dilata- 
tion of the cavity, from hypertrophy, from dilatation or weakness 
of the great vessels, or indeed from whatever causes of palpitation 
of the heart, as it is for those that depend upon simple, pure, un- 
mixed ansemia. 

In cases of pregnancy, accompanied with palpitation, and 
convulsive, or rather what you might prefer to call nervous ac- 
tion of the heart, among the very best resources of the materia 
medica is the digitalis purpurea. This is a pure narcotic, which, 
by its influence upon the nervous system, when properly admin- 
istered, diminishes its excessive perceptivity, and in doing so, is 
capable of lessening the manifest result, within the organs, of that 
excessive perceptivity, which is always accompanied with exag- 
gerated action of the reflex innervation. 

Everybody, whether painter or poet, musician, agriculturist 
or physician, becomes more or less a routiner; that is to say, he 
acquires habits in his actions; whence it is, I suppose, that you 
find some physicians who never prescribe digitalis except in pow- 
der ; others, who confide in it only when used as the tincture of 
the plant ; while some never permit themselves to employ it ex- 
cept prepared according to the formula of Withering^ infusion. 



510 DISORDERS OF PREGNANCY. 

I am in the latter category, and I scarcely ever give digitalis, 
unless in the form of Withering's infusion, except where I give 
it to young children, and then I always employ the tincture. In 
the class of patients of which we have just been speaking, I 
commonly prescribe, when I think the use is indicated, half an 
ounce of Withering's infusion of foxglove, which I direct to be 
repeated once in eight hours. But I think it is necessary always 
to add a very clear and understandable caution, as to the repeti- 
tion of the doses. No physician ought to trust himself to pre- 
scribe such a medicine, unless he can in person, or by means 
of a confidential agent, note the progress of its therapeutical force 
in bringing about the desired control of the circulation. When 
the pulse begins to fall in frequency, the administration of the 
drug should be either wholly suspended, or lessened as to the 
doses, or augmented as to the periods; because, the collapse 
which follows the excessive action of the medicine, being sudden, 
is a thing not to be thought of for a pregnant woman, for it is 
frightful enough for the non-gravid. " In morbis pectoris, per 
vias urinae ducendum est," is an ancient precept, and the digi- 
talis purpurea, perhaps, of all the articles in the materia medica, 
is most highly endowed with the diuretic force, which renders it 
peculiarly appropriate in the affection under consideration. 

I need not lengthen this letter by specifying directions as to the 
prescriptions, and the formulae of prescriptions, which will be re- 
quired in the course of the treatment. If you be really well 
founded in the knowledge of anatomy and of physiology, you will 
be able, in contemplating the rate of the functions of the different 
parts of the body, so to direct your therapeutical prescriptions 
and your hygienical ordinances, as to correct, if possible, the 
local derangement, and by removing them, absolve the nervous 
system from the necessity of perpetually perceiving these local 
derangements, and perpetually contending against them by ex- 
citing what is Called reaction. 

There is another distressing affection which accompanies preg- 
nancy, and about which I am desirous to say a few words. I 
mean the inconvenience and pain resulting from a strain of the 
pelvic articulations. The symphysis pubis and the sacro-iliac 
junction ought to be firm; the least motion of the pieces of bone 
that are bound together by these articulations, is attended by a 
feeling of weakness, insecurity and pain, in the highest degree 



DISORDERS OF PREGNANCY. 511 

annoying. I have seen a patient who could not take ten steps 
across her chamber without producing a sensible motion of the 
right and left ossa-pubis ; so that, when she would stand upon her 
right foot, the os pubis of the right side would be raised at least 
a quarter of an inch above the left one, and vice versa. But 
if you understand the nature of the auricular symphysis, you 
will perceive that the pubis cannot become a movable joint 
without involving more or less motion in the sacro-iliac junction, 
and that such motion must give a feeling of unsteadiness, 
insecurity and debility, than which nothing can be more distress- 
ing: the woman feels as if she was going to fall to the ground 
between her thighs. Her inability is so great, that she is obliged 
to call for assistance to turn in bed, or if not assisted, she first 
sits up in bed and then lies down on the opposite side. 

It is probable that the perpetual sprain, the weight, and the 
pressure occasioned by the presence of the gravid womb w T ithin 
the circumference of the superior strait, and the resistance of the 
abdominal muscles against the distending, growing uterus, all of 
which force, it must be admitted, is concentrated or expended 
upon the pelvic articulations, may determine a state of disease or 
abnormal vitality there, followed by infiltration and relaxation, or 
partial softening of the fibrous material ; the result of which is the 
articular relaxation in question. 

It is a vulgar opinion that the pelvic joints do naturally open 
to give escape to the child in labor ; and among the common 
people, it is by no means rare to find them making use of 
ointments and lotions for the purpose of promoting the softening 
and relaxation of the articulations. All such attempts are both 
unnecessary and futile ; whenever the relaxation does take 
place, it arises from the causes which I have just narrated; — 
causes that are, perhaps, fortified by a rheumatic vice which 
has fallen upon the parts. 

The vitality of these low-lived tissues is so slow in its processes, 
that a great deal of time is required to effect any changes in their 
density, and I believe you will make a great mistake, if, when a 
woman, after her child is born, complains to you of relaxation 
of the symphysis, you should admit, what she will probably sup- 
pose, namely, that the relaxation was produced by the strain of 
the labor. A labor shall scarcely last long enough to effect such 
great modifications in the life of these half inorganic materials. 



512 DISORDERS OF PREGNANCY. 

I have met with a good many examples of this distressing acci- 
dent in my clinical practice, some of which have been perfectly 
cured in the course of a very few weeks, and some which have 
never recovered, and seem as if they were destined never to re- 
cover. The patient is so distressed, that she asks for a treatment ; 
nay, she asks for a cure. Now what shall be the treatment, what 
shall be the method of cure ? Suppose you had a patient laboring 
under an inflammation of the hip, of the knee joint, of the ankle, 
or of any other articulation, would you not treat it with a splint ? 
And why with a splint? Would it not be, that by means of the 
splint, you might treat it by rest ? Now the word rest is the other 
expression for the word splint. An inflamed joint, like a broken 
bone, requires rest, as a general rule, although it may have more 
exceptions than the case of the broken bone ; yet it has few excep- 
tions, for even in the case of the broken bone, it might happen, 
that where a false joint is formed, or is about to be formed, the 
motion might determine a cure by re-exciting the power of the 
periosteum, which is the bone-producing power. 

I don't see much use in giving drugs to a woman who com- 
plains of a loose articulation ; you might, perhaps, reasonably 
resort to some anti-rheumatic medication, in the cases which you 
should deem dependent on a rheumatic vice, existing either as 
the original cause of the relaxation, or continuing to prevent its 
cure, or as succedaneous, supervening upon a part weakened by 
the causes before indicated, and thus inviting an attack. Con- 
sider these points, and act accordingly. 

I ought to have observed, that Prof. Moreau, author of the 
Traite Pratique des Jlccouchemens, at p. 47, vol. 1st of his admi- 
rable work, assigns pelvic relaxation as the cause of some of the 
slow and difficult labors that are occasionally met with. He says, 
the muscles that are auxiliary to the uterus, having no longer a 
firm insertion on the vacillating bones of the pelvis, painfully affect 
the symphyses by their contraction ; and that the woman, restrained 
by fear of the pain consequent upon the contraction, fails to bring 
into play these accessory powers. So that the uterus, left to the 
resources of its own energy alone, frees itself slowly, and with 
difficulty, from the products of conception. 

I am about to violate again, a rule that I had laid down in the 
composition of these letters, which was, to put them in very few 
quotations from other authors ; but the disorders arising from the 



RELAXED SYMPHYSES. 513 

cause in question, are in all respects so interesting to the practi- 
tioner, that I will not resist the temptation I feel to lay before you 
a translation from the same Prof. Moreau's work, the reading of 
which will serve to throw an abundant light upon the subject; 
and as I have not met in my practice with any case so important, 
of our disorder, I think I shall do you a service in laying before 
you that of Prof. Moreau. 

The following are M. Moreau's words: "Mad. D. of Paris, 
aged thirty-three years, of an apparently sound constitution, had 
been weak and delicate during her childhood, and had also 
exhibited some signs of rickets, marked by slight tumefaction of 
the articular extremities of the long bones. She became regular 
at fourteen years and a half, and then grew rapidly. From this 
time up to the period of her marriage, she enjoyed perfect health, 
saving that there was always a little weakness of the ligaments. 
She, was liable to slight sprains, and had very little strength in 
her wrists. She was married at the age of six-and-twenty years, 
and soon became pregnant. The first steps of this new condi- 
tion evinced nothing extraordinary : at about the second month, 
an excursion of five leagues from Paris, which she made in 
the course of one day, brought on a general uneasiness accom- 
panied with sharp pains, that were thought to threaten an abor- 
tion. The physician had her bled in the arm, ordered her to 
rest, gave her tepid baths and directed a light regimen. The 
pains which during the first eight days had been so sharp that 
the patient while in bed was incapable of the least motion, be- 
came quiet ; at least, so that she could be placed on a sofa. At 
the end of a month, she tried to walk, but though the attempt 
gave her no pain, she could not take a step without finding her- 
self ill. 

"This inability to walk continued for some time; however, 
towards the end of pregnancy the young lady gained strength, 
and was able to walk with a little less difficulty. 

"Labor pains came on in the night of the 16th of October, 
1830, and had continued for twenty-four hours, when the forceps 
was employed, to assist the delivery of a male child, in good 
health, whom the mother in vain attempted to suckle. 

"During the first fortnight of the lying in, she had severe 
pains in the hips and the parts of generation, which were at- 
33 



514 RELAXATION OF THE SYMPHYSES. 

tributed to lacerations occasioned by the passage of the child's 
head and the use of the forceps. 

" After this, she made an attempt to get into an easy chair, but 
fainted and was again put to bed. 

"At the end of six weeks the lady attempted to walk from her 
bed to the sofa, leaning on the shoulders of assistants ; but at every 
attempt she had sharp pains in the articulations of the pelvis, and 
felt as if her body would slide down between her legs. 

"Five months having elapsed, she went, by the advice of her 
physician, to the country. There, her hips being bound round 
by a- bandage kept in place by understraps, she attempted to 
walk in the garden, but the attempts were always attended with 
suffering. Whenever the understraps were loosened, she said 
she had a sort of bursting sensation, with a desire to sit down, 
or to lie down. 

"For ten months she made use of gelatinous baths, baths of 
Bareges-water, and saline or astringent injections, but without any 
appreciable advantage. A consultation was then held between the 
accoucheur and MM. Magendie and Amussat. It was determined 
at the consultation that there was relaxation of the symphyses of 
the pelvis, the effect of which was that when the patient was 
placed upon her feet and left to herself, she was incapable not 
only of maintaining such position or of walking, but also of adduct- 
ing the thigh. 

" Madame D. was now ordered to wear a belt better constructed, 
and stronger than the one which she has hitherto used. This 
belt embraced the hips, both trochanters, and the upper parts of 
the thighs, so as to approximate them, and maintain the approxi- 
mation with great energy. 

"When supported in this manner, it is certain that Madame D. 
could begin to walk, not without difficulty, in her chamber, and 
sometimes in the street; but she could neither ascend nor descend 
a stair: it was necessary to carry her, to enable her to get up 
four or five steps. After two years of care, and of a treatment in 
which sulphurous, gelatinous, and aromatic baths had been em- 
ployed, her health improved; she could walk better. At the end 
of 1832, she was able to take short walks, prolonged sometimes 
to the extent of five and twenty minutes; still, however, she 
always had pain on the day following such an effort. 

"In the month of March, 1833, she became pregnant again. 



RELAXATION OF THE SYMPHYSES. 515 

In the course of the first three months there was nothing peculiar, 
except that she experienced great difficulty in walking. At the 
end of three months, her sufferings increased ; at which time I 
w T as called in for my opinion in the case. In spite of her suffer- 
ings, and in hopes that the open air would give her strength, she 
continued until the fifth month to go to the gardens of the Luxem- 
bourg, a promenade from which she was separated only by the 
width of a street. 

" Towards the end of August, upon returning from a walk, she 
had such violent pains in the hips, thighs and loins, that she 
was obliged to keep first her chair, and her sofa, and then her 
bed, for the remainder of her pregnancy. 

" On the first of December, 1833, at half-past four o'clock in the 
morning, after a labor of a few hours, which was neither long nor 
very painful, she gave birth, naturally, to a fine healthy boy. 

" Immediately after this second accouchement, Madame D. lost 
all power of motion. In bestowing upon her the cares required by 
her condition, it was necessary to move her legs one at a time; 
but the limbs could never be moved without causing pains so 
violent, that the patient could not or would not move, even to 
satisfy the most imperative wants. She groaned incessantly; 
cried out whenever she was touched; and if, in her uneasy sleep, 
she happened to change her position, she was immediately 
awakened by the pain, and unable, without assistance, to recover 
the position she had just quitted. Still there w T as no fever, nor 
enlargement in the articulations of the pelvis, nor change in the 
color of the skin. The left leg was weaker than the other. The 
surface of the mons acquired such an extreme sensibility, that the 
patient believed that the hair had become sensible, because the 
least touch or the least friction gave her pain. 

" Narcotic and emollient applications, without recourse to bleed- 
ing, diet, the use of diuretic and sedative drinks, and two slight 
doses of purgative medicine, coupled with the most perfect im- 
mobility, sufficed gradually to dissipate these sufferings, which, 
in the course of a month after her confinement, totally disap- 
peared. 

"Nevertheless, the movements of the lower extremities became 
less and less free. One fact ought to be mentioned, in which the 
case differed from her former confinement; she could not abduct 
her limbs. Whenever she wished to move them, she was obliged 



516 RELAXATION OF THE SYMPHYSES. 

to move them both together to the same side ; to effect which, she 
was, and still is, obliged to flex the knees, by drawing up the 
feet towards the pelvis, and then incline both the limbs towards 
the right or the left, as in incipient paraplegia. 

" On several occasions I expressed to the family my desire to be 
assisted by the advice of some of my brethren, and especially of 
those who had formerly had charge of the patient, and who still 
saw her from time to time. 

" Consequently, at the beginning of April, 1834, I met MM. 
Magendie and Amussat. After an attentive examination, these 
gentlemen who had observed the case during the first confinement, 
ascertained that there was an enormous increase of the mobility 
and separation of the symphyses. 

"It was agreed at the consultation, that, as a basis of treatment, 
the lady should be sent to the country, to a dry and elevated situa- 
tion, where she should be exposed upon her bed, to the influence 
of pure air and solar light; and that she should take saline, alka- 
line, sulphurous or aromatic baths ; that she should make use of 
an animal diet, which should be tonic without being too stimu- 
lating; and that above all, she should return to the use of a mode 
of constriction of the pelvis, which should be strong, methodical 
and permanent. 

"My colleague M. Amussat, who took charge of the treatment, 
and gave the most assiduous attention to the patient, was kind 
enough to see that the bandage should be prepared by a careful 
artist ; a sort of mechanical girdle, which should embrace the hips, 
taking as its point oVappui the trochanters ; the pressure to be regu- 
lated by means of screws. When the apparatus was applied, the 
patient could bear it only for a quarter of an hour at a time, 
although the buckles and the screws were not much tightened. 
The result did not answer the expectations that had been indulged, 
for, as soon as the machine was applied, she was attacked by slight 
fever, accompanied with very decided nervous spasms; symptoms 
that were reproduced upon every repetition of the experiment. 
It was necessary to give up the means as too energetic, and to 
recur to the use of the simple bandage furnished with buckles 
and strong straps, which the patient could tighten at will. 

"Notwithstanding the most careful attention, — in spite of the 
perseverance with which the above treatment has been carried 
out for two years; in spite of the employment of other therapeutical 



RELAXATION OF THE SYMPHYSES. 517 

means, which we shall omit, with many other interesting details 
to mention, the lady remains very nearly in the state in which 
she was in the month of April, 1834. 

"Having been called to her five or six weeks since, to take care 
of her in a new pregnancy, which began at the end of November, 
1835, I find her in the following condition : 

"In the course of the two years during which I had lost sight 
of her, she has grown thin ; the digestive functions are torpid, and 
often performed with pain ; the alvine and urinary excretions are 
voluntary and easy; the sexual organs retain the free exercise of 
their functions ; the sensibility of the legs and thighs natural, but 
they have sensibly diminished in size, are more flaccid, softer, and 
have almost entirely lost the power of motion ; flexion and exten- 
sion are still difficult ; it is impossible for her to lift up her limbs, 
and she cannot quit the horizontal posture. Upon exploring the 
symphysis of the pubis, either internally or externally, the bones 
are found more separate than in the ordinary condition. Upon 
lifting up one pubis, and pushing the other in the opposite direc- 
tion, I thought I could perceive a vacillation of the bones which 
the patient said she also could perceive." 

I have nowhere met with a more interesting detail of the effects 
of the relaxation of the symphysis of the pubis, than the one which 
I have now laid before you. Nor have I seen one attended with 
so total a loss of power, as this described by Prof. Moreau. 

I long had charge of the case of a lady, laboring under a strange 
susceptibility of the nervous system, accompanied with a loss of 
innervative power, so that, although she was at ease, and appa- 
rently well in a state of recumbent repose, a slight, even a very 
slight muscular effort was often observed to be followed by a severe 
attack of lypothymia. The digestive powers were not particularly 
affected, nor were the assimilative functions much interrupted by 
these strange maladies. It seemed at times that she was greatly 
benefited by the pelvic bandage, and I doubt not, that the motion 
of the lower extremities was much more possible, and much less 
painful, when the bones of the pelvis were held in contact by the 
aid of the girdle. She has recovered and lost again, two or three 
times, the power of voluntary exercise ; she has given birth to 
several children, and is now in the possession of comfortable 
health. I always supposed that her maladive condition took its 
radiating point from an affection of the pelvic symphyses, which 



518 RELAXATION OF THE SYMPHYSES. 

came on during fatiguing journeys, while pregnant with a heavy- 
male child. I could also produce pain in the symphysis pubis, 
by pulling the cristas of the ilia apart with my two hands; I could 
never give any pain by pressing the pubes together by placing my 
hands on the exterior of the pelvis. 

I believe that these cases ought to be regarded as cases of 
rheumatism of important articulations ; and whether they be 
rheumatic or not, in their incipiency, the sprain, and injury done 
to the joint, by gestation and labor, are sufficient to invite attacks 
of rheumatism, which, having once effected a lodgment in the 
tissue, can be with difficulty, or not at all displaced. 

In cases of relaxation of the pubic symphysis refusing to yield 
to a treatment consisting of an absolute rest of the articulation, 
effected through recumbency and bandaging, there will also, I 
think, be good reason to accuse the part of rheumatism, provided 
we exclude from the diagnostic any possible condition of active 
inflammation tending to produce suppuration or caries of the joint. 

In the case which I have cited at such length from Prof. Mo- 
reau, you see that the patient suffered for many consecutive years, 
and that the last note of the case left her in still very ill health. 
Do you think that such grave disorders of the health, and so great 
a persistence in them, could possibly depend upon mere relaxa- 
tion of the fibro-cartilage that binds the ossa pubis together? Do 
you not rather concur with me, in the opinion just now expressed, 
that there must be some disorder over and above the state of re- 
laxation in which the articulations are known to be? And is it 
not likely that the disorder is arthritic? I should think that if 
you should come across a case such as that of Prof. Moreau, you 
would resort to an anti-rheumatic treatment ; and that for the sub- 
duction of the arthritic disorder, you w^ould at least come to the 
conclusion that the use of a powerful counter-irritation and deri- 
vation like that of the seton, might assist to restore the patient's 
health. I should think that such a seton as that of Dr. Grauiex 
w T ould scarcely be objected to by the patient herself, as it would 
afford some reasonable ground of hope to relieve a torturing and 
disabling disorder. 

I have proposed such a seton to a young lady at present under 
my care, who has suffered for years from manifest relaxation of 
the interpubic ligaments, whose general health, however, has not 



ABORTION. 519 

been deeply mined, but who declines to admit of the application 
of the remedy. 

C. D. M. 



LETTER XXXIX. 

Gentlemen: — Among the diseases and accidents of preg- 
nancy, none are more common and more vexatious than those 
connected with miscarriage and abortion. 

The full term of pregnancy extends, as I have stated, to about 
the tw T o hundred and eightieth day from the fecundation of the 
ovum ; it is more prudent, in making the calculation for the term, 
to begin the computation from the day of the last catamenial 
show: two hundred and eighty days from this date, the woman 
ought to expel the child. It is in this manner that I have made 
the computation for my patients for many years past, and as yet 
have found no reason for changing my method or habit. It is 
true that the Jewish women, as I mentioned in a former letter, 
begin their computation after the eighth day subsequent to the 
disappearance, and they say that the calculation serves them well ; 
but the other method has also served me well. 

Some years ago there was a trial in England involving the 
question of the duration of pregnancy. It was called the Gar-, 
diner Peerage Case, and was instituted for the purpose of settling 
the title of a claimant to that peerage. Many eminent medical 
men in England were examined on the occasion, and the result 
w T as, that no absolute term of pregnancy was ascertained. Moved 
by the interest excited in that case, Dr. Merriman, of London, 
took the greatest pains to ascertain the duration of pregnancy in 
many women, and he succeeded in satisfying his mind of the 
great correctness of the computation for one hundred and fourteen 
cases of mature children. The results of these inquiries he pub- 
lished in the Lond. Med. Chir. Trans., vol. xviii. part ii., at p. 
338. He gave a tabular statement as follows: There were 
born at 



520 



255 days, 1 


14 in 39th week. 


288 days, 5 


256 " 1 


274 


days, 4 


289 << 2 


259 " 1 


275 


" 2 


290 " 2 


3 in 37th week. 


276 


« 4 


292 " 4 


262 days, 2 


277 


" 8 


293 " 2 


263 " 2 


278 


" 3 


15 42d week. 


264 " 4 


279 


" 3 


295 days, 1 


265 " 1 


280 


" 9 


296 " 2 


266 " 4 


33 in 40th week. 


297 " 2 


13 in 38th week. 


281 


days, 5 


298 " 4 


267 days, 1 


282 


d 2 


301 " 1 


268 " 1 


283 


" 6 


10 43d week. 


269 " 4 


284 


" 1 


303 days, 1 


270 " 1 


285 


" 4 


305 " 1 


271 " 2 


286 


« 3 


306 " 2 *■■ 


272 " 2 


287 


" 1 


4 in 44th week. 


273 « 3 


22 41st week. 





From the foregoing table it appears that the term, or the dura- 
tion of a pregnancy, is not absolutely fixed, or that there is a con- 
siderable latitude as to the number of days that the foetus may 
remain in utero; some of them being rendered "mature" sooner, 
and some later, according to the amount of vital force they are 
endowed with. It is relative, perhaps, also to the strength and abi- 
lity of the maternal constitution, and in some degree, probably, 
according to the placental attachment and connection, as more 
or less extensive and perfect. 

But, while the natural term of a pregnancy is about 280 days, 
such is the delicacy of the attachment by which the foetus is united 
to its parent, that many causes are found sufficient to separate it 
from the lining surface before its time ; and numerous diseases, to 
which its frail nature renders it liable, serve to bring its life to a 
premature conclusion. By its death, the ovum becomes a foreign 
body, and is expelled by the womb which it now irritates patho- 
logically, and thereby excites the contractile force of its muscles, 
so as to give rise to the pains or contractions of a miscarriage, as 
well as the bloody discharge that usually attends the contractions. 

It should be considered, that though the foetus is contained 
within the cavity of the womb, it is prevented from all direct 
contact with that organ, except at one point. It floats in the 
water of the amnios, and the interior of the womb is lined every- 



ABORTION. 521 

where by the amnion and chorion, and the decidua also, except 
at that part of the uterine surface which is invested with the pla- 
centa. 

This placenta is to be properly esteemed as an expansion of 
the main trunk of the foetal aorta — inasmuch as the aorta of the 
embryo divides, above its pelvis, into two umbilical branches, 
which, as they pass down towards its brim, give off the iliacs — 
and then reflecting themselves upwards on each side of the blad- 
der, proceed through the umbilical ring and along the cord to the 
placenta, which is another name for their umbel-like divisions, 
expansions, or ramifications. When the aorta has thus pushed 
its extremity against the living surface of the mother, it has suc- 
ceeded in establishing the utero-foetal union, and this is the only 
point at which that union exists ; everywhere else the womb is 
protected against direct contact by the interposed membranes, as 
before observed. It might, without a violent stretch of the imagi- 
nation, be conceived, that, in this .case, the heart of the foetus has 
projected its vessels to a great distance, and expanded them upon 
the vital surface of the mother, in order to obtain on that living 
surface the influences of the oxygenated blood of the parent; and 
we can discover an analogy in the case, to what happens in 
the brain, which, in order that it may receive the impressions of 
light, projects from its substance the optic nerves, extends them 
beyond the walls of the cranium, and expands them as retina on 
the choroid coat, in order that a larger surface may be exposed to 
the radiation. Or again, just in the same design, the trunk of the 
pulmonary artery divides itself into innumerable arteries, arterioles 
and capillaries, in order thereby to expose a given quantity of 
blood on a vast superficies, to the action of the oxygen of the 
atmosphere. 

This point of attachment of the embryo to the womb, has been 
lately called its mesenteric attachment, and it must be easy to 
conceive that, whatever may have power to destroy that mesen- 
teric union, has equal power to arrest the progress of the foetal 
life, for if that attachment be partially destroyed, the foetus will 
slowly or suddenly perish ; or possibly recover, if the injury be 
not very extensive. 

For the most part, the union betwixt the placenta and the 
womb, is very slight; it may be overcome by a blow on the wo- 
man's abdomen, acting directly on the place of union. Contrac- 



522 ABORTION. 

tions of the womb, affecting that part of the superficies of the 
organ, on which the afterbirth sits, may detach it. Sudden and 
violent augmentations of the momentum of the blood's motion in 
the maternal vessels, sometimes are sufficient to break the union; 
and this happens in consequence of the impulse causing some 
drops to escape from the womb, lodging betwixt it and the pla- 
centa — thus peeling or dissecting it off, little by little, until a suf- 
ficient quantity is removed to destroy the life of the embryo. 

Sudden and violent muscular motions of the mother, as in 
recovering from falls, in stooping, in lifting heavy weights, in 
ascending stairs, in running, dancing, leaping, &c. ; in riding over 
rough roads, or on horseback; all these are sufficient, on certain 
occasions, to break the connection of the afterbirth with the 
womb. 

Emetics — by the relaxing influence of nausea, followed by the 
intense efforts of the muscles in vomiting — also serve to detach 
the placenta in some individuals. 

The violent and drastic operation of cathartic drugs, as aloetics, 
senna, &c, by the great tenesmic action they introduce, and by 
the affluxion and heat which they determine to the pelvic organs, 
are also sufficient causes of abortion. 

The action of blisters, and the internal use of cantharides and 
certain essential oils, may also, by the irritation of the neck of 
the bladder, involve, in great irritation, the adjacent and con- 
nected womb, and so serve as causes of abortion. 

Ergot is, doubtless, sometimes employed for the purpose of 
procuring abortion. I am aware, however, of only one case in 
which it was used for that object. A woman, a widow, about 40 
years of age, in full, vigorous health, after an illicit intercourse, 
found herself pregnant. She had a large family of children, and 
fearing the consequences of her fault, she procured, from an apothe- 
cary, a portion of ergot, which she took, with a view to cause the 
expulsion of the ovum, at about the fourth month. The ergot made 
her very sick, and as the vomiting alarmed her for her safety, she 
sent for me in great fear of the consequences, and confided to me 
her painful secret. I warned her against the enormity of her fault, 
and seeing that the attempt to excite the womb's action w T as 
happily a failure, advised her to leave town for some months, 
which she did, in order to be confined at Boston. I have men- 



ABORTION. 523 

tioned this case, the only one within my personal knowledge, of 
the use of ergot in a healthful gestation, for the purpose of excit- 
ing the uterine contractions. In this case it signally failed ; and 
I am strongly inclined to believe that, although the power of 
ergot to excite the muscular action of the womb in labor is unde- 
niable, it is not certain that it can excite those motions ah origine. 
It very certainly often does fail to set the womb in motion when 
given to facilitate miscarriages already in progress, but going on 
too slowly. 

If we consider for a moment the extreme tenuity of the mem- 
branes and vessels of the early embryo, we ought rather to be 
amazed at the power it has to live on to term, than surprised at 
the occasional cessation of its existence in the early stages of its 
intra-uterine life. The least obstruction of the delicate umbilical 
vessels, or of its omphalo-mesenteric apparatus, would destroy it. 
The least rupture, perhaps, of the hyaloid membranes of its re- 
ticulated magma would cause its death — and an error loci of its 
blood-globules, as they proceed to mark out the traces of its blood- 
vessels, might cause an inevitable cessation of its existence. 

It is probable that a major part of the abortions met with in 
practice, are the results of a failure in the vital forces and arrange- 
ments of the embryo, and not of a faulty action of the womb it- 
self, or some accident, or emotion of the woman herself, some 
imprudent step, gesture, or posture. 

If the embryo dies in utero, the ovum commonly soon ceases 
to possess any vital property, and then the womb, by some sort of 
organic perception ; by ceasing to grow or expand ; by the irritation 
of a present foreign body, comes to a full stop, or arrest of those 
living and progressive developments under w T hich it has been act- 
ing since the commencement of the gestation — a new principle 
of activity is awakened in its organism, its muscular fibres begin 
to constringe themselves, the superficial extent of the uterine 
cavity grows less and less under these contractions, and the em- 
bryo and the ovum are cast out of its orifice into the vagina, from 
which they are soon pressed forth, or fall away by their own 
weight. 

Although the death of the embryo involves a certain cessation 
of the projection of its blood to the vessels of the placenta, and. 
notwithstanding this cessation generally, is very speedily followed 
by the expulsive action of the womb, it is not always soon fol- 



524 ABORTION. 

lowed by the latter effect. A lady conceived, about the 20th of 
April, 1842, and consequently made arrangements for her ac- 
couchement for the 20th of January, 1843. The pregnancy went 
on well until about the 5th or 10th of August, when she had a 
very slight show, and there was a complete arrest of the usual 
developments. She was at various times affected with slight ap- 
pearances of her catamenia, as she supposed, but without any 
flooding, until the 3d of January, 1843, when she sent for me, 
saying she had^suffered extreme pain, like the pains of labor, for 
some hours, but was now easy, though she thought something 
was escaping from the vagina. Before examining the patient, I de- 
tected the ovum partly in the vagina, and partly embraced within 
the cervix, which I removed with the index finger, and, upon 
carefully examining it, found that it was the unbroken ovum of 
a foetus of three and a half months, apparently. The ovum itself 
contained a sort of granular brown and thick fluid, while the 
foetus, also of a mummy color, retained its lineaments, although 
considerably macerated by its long residence in the waters. The 
placental portion of the ovum was red and fresh looking, and had 
evidently retained more or less vitality up to the period of its 
separation from the womb. 

I think I can safely assert that, in the course of my practice, I 
have met with near twenty cases of the protracted residence of the 
ovum in the womb, after the death of the embryo. I have had 
under my care, several cases where it has certainly remained five 
months after its death. Nor, indeed, is there any reason for sur- 
prise at this, if we reflect, that numerous examples have been 
met with, in which, in twin pregnancies, one of the foetuses has 
perished at the third or fourth month, and yet remained in utero 
until the other twin had gone to the full term of utero-gestation, 
become fully developed, and been safely delivered at the same time 
with the aborted twin. 

A miscarriage is not always painful. Women sometimes ex- 
clude the ovum, when at an early stage, by such gentle and easy 
contractions, and by so ready a dilatation of the os uteri, that they 
are hardly sensible even of a degree of uneasiness. In general, 
however, it happens that when the womb does begin to contract 
for the expulsion of its contents, it does so with very great vigor, 
and the contractions are both long and frequently repeated. If they 
are violent, they press the ruined ovum into the narrow canal of 



ABORTION. 525 

the cervix uteri, which, by the resistance of its sphinctorian fibres, 
opposes with great energy the distending or dilating e*Tort of the 
advancing ovum. This resistance causes pain, often of the most 
acute kind, so that women, now and then, have informed me that 
they suffered much more distressing pangs in this way, than 
in their labors at full term. This is not surprising, if we reflect 
upon the length of the canal of the cervix, and the thickness and 
density of its walls, pressed open thus, by a sort of direct violence 
or force. 

Let it be observed here, that, in the early stages of pregnancy, the 
ovum inhabits the body and fundus of the womb, and that it has not 
hitherto appropriated any part of the structure of the cervix as its 
cavity or habitation. Hence it happens, that, though the body and 
fundus may have pressed and pushed the ovum quite out of their 
cavity, which is now nearly empty and unoccupied, they are unable 
to force it quite out of the canal or cavity of the cervix. This tubu- 
lar or acutely conical canal, now grasps it firmly, and will not let it 
go, keeping up a constant irritation and disturbance of the organ, 
that maintains the hemorrhagic nisus, if there be any, or ex- 
cites and produces it, if it do not already exist. The inference 
from this remark is that, in such cases, if the physician remove the 
half expelled ovum, or after-birth, from the grasp or gripe of the 
cervix and os uteri, he will remove the cause of distension, and 
allowing the w T omb to contract perfectly, bring about an instant 
cessation of the hemorrhage. It will, therefore, be his duty in all 
cases apparently depending on such cause, to ascertain its exist- 
ence and operation, and take the proper measures for its obvia- 
tion. 

I have observed many cases, in which the ovum has been thus 
detained many hours, and even many days, keeping up, as before 
remarked, a constant irritation, with hemorrhage sometimes of 
frightful violence, that always ceased as soon as I could take away 
the mass in question. 

The great and very important principle, that in order to the 
suppression of uterine hemorrhage, connected with gestation, it 
is necessary to empty the womb, ought to be more universally 
known or admitted, than it seems to be even among certain 
medical persons of considerable experience. 

When called to a married woman who is flooding, the first ques- 
tion should be directed to the ascertaining if she be pregnant, or 



526 ABORTION. 

not. If she say she is not, and yet be of that age, and in those 
circumstances that expose her to the liability to be pregnant, I am 
reluctant to act upon her responsibility. If she say, I was preg- 
nant, but I miscarried yesterday, or last week, or a month ago, 
and yet I am suffering hemorrhage at the present moment, I 
should always suppose her opinion, or that of any other person, 
not worth taking, until I should have learned for myself, by my 
own sense of touch, that she was not misinformed — for what 
should cause a woman of the child-bearing age, and in good 
health, what, I ask, should cause her to flood? If permitted to 
make the examination by touching, I could satisfy my own judg- 
ment on the question. Such is the course I take, always, where 
the exigency of the symptoms of hemorrhage calls for it — and I 
must say, that in the larger proportion of cases, when there has 
been pain, and w T here hemorrhage has continued after the pain 
is gone, I have, upon touching, found the ovum grasped in the 
cervix, and upon dislodging it thence have found the hemor- 
rhage to cease at once. It appears to me to be inexcusable to 
permit a woman to lose pint after pint of her blood, rather than 
take this disagreeable mode of learning what our duty in the case 
may be. Such losses of blood are followed, in certain cases, by 
long terms of broken health, and sometimes by weakness which 
is never fully recovered from. 

It is better, therefore, to determine with accuracy what the in- 
dication of treatment is, and having got that, the path of duty lies 
plain before you. I have the less reluctance to speak in this man- 
ner, because I have so many times been called upon in consultation 
where the patient had already lost a large quantity of blood, the 
medical attendant being persuaded either that there had been no 
pregnancy, or that the pregnancy had already terminated some 
time before. 

Within three days a friend has sent me the uterus of a patient 
brought into one of the public institutions dying — who was said 
to have miscarried several days before. This uterus, which was 
in a state of sphacelation, contained the placenta of a foetus of 
four months. It was partially detached from the placental super- 
ficies — a separation that had occasioned a hemorrhage of forty- 
eight hours' duration. From the situation and size of it, I sup- 
pose it could have been removed with a placenta hook, or a 
small pince a faux germe, without risk or difficulty. It is evi- 



ABORTION. 527 

dent, that the person who had the case under treatment, was not 
aware that the placenta was not delivered. 

True it is, that, in some cases of abortion, it is not within the 
competency of the medical attendant to extract the placenta. 
The long cylindrical canal of the cervix closes soon after the ex- 
pulsion of the waters and embryo; the womb sometimes ceases to 
contract, and the finger cannot gain access to the uterine cavity, 
and even if it can, it is not always possible to remove the placenta, 
which occasionally adheres with abnormal pertinacity. Attempts 
with a proper small forceps, with the placenta hook, by means of 
ergotism and other means, should always be carried as far as a 
sound discretion will permit ; but all rude and forcible attempts 
to procure extraction should be regarded as equally dangerous 
as the continued stay of the after-birth in the cavity. I have 
many times preferred to leave the remains of the ovum to mace- 
rate and putrefy in the womb, to the dangerous risk of provoking 
inflammation of the organ by forcibly tearing it from the womb. 
In my own practice, I had never occasion to regret my decision. 
Yet I saw in consultation, a lady, some two years ago, in whom 
the placenta of a four months foetus was never extracted, and who 
lost her life by metritis some days afterwards. The case of the 
uterus, recently presented to me, and of which I just now spoke, 
is another one which ought to induce any medical man to pause 
and consider carefully the indications of duty, before he should 
either decide to act, or refrain from interfering. 

To a young practitioner, or to the general practitioner unac- 
customed to the treatment of the disorders of pregnancy, a call to 
a case of abortion is a source of discomfort, embarrassment, 
and even of dread. I doubt not, my young friends, that in the 
commencement of your career, you will often have occasion to 
experience the pangs of doubt, and the consciousness of incapa- 
city, which the want of a familiarity with such scenes will inevi- 
tably produce. But, as I often told you in the lectures, your 
principles of medicine should guide you and protect you against 
any uncertainty, disquietude, or alarm. 

In the present case, the principle chiefly concerned is that of 
the innervation of the womb. You, I presume, understand the 
principle well, and you will confidently depend upon its power 
to save your patient in the wildest and most frightful eiiiision 01 



528 ABORTION. 

blood, because you will always know how to incite and Invigorate 
the uterine innervation, where it may be possible to do so, and to 
stay the effusion of the blood. 

But, wherever the means within your reach prove incompetent 
to rouse the languid, exhausted or expiring forces of the organ, I 
cannot well conceive how it should be, that the youngest and most 
inexperienced member of the Class, could suffer himself to be at 
fault for a moment in deciding upon the points of his duty. That 
duty will depend, in the first instance, upon the actual state of the 
constitution of the patient, and upon the views he may take as to 
the propriety of preserving, or the necessity there may be of 
sacrificing or disregarding the ovum. If the woman be not evi- 
dently exhausted from the losses she has already sustained, it is 
easy to perceive that little danger will attend some additional loss. 
Or, if she be already much reduced in strength, — the condition to 
be discovered by inspection of her countenance ; by inquiries as to 
the force of her muscular apparatus; the color of the surface as 
to paleness or the reverse ; the circulation, as indicated by the 
arterial pulse ; the respiration, from observing its frequency and 
its degree; the intellect, to be inquired into by eliciting from her 
some intellectual expression, — he will at once resolve to interfere 
for the immediate rescue of the female, or he will determine to let 
it go on. 

I can see that a medical man, under such circumstances, has 
no right, in the exercise of his professional avocations, to do any act 
or thing which will insure the destruction of the young embryo, un- 
less the necessity of the case be so apparent and so urgent as to ex- 
clude entirely all idea of exposing her to further risks with a view 
merely to the conservation of the delicate creature within. For 
example, if you are called to a patient who is flooding in the third 
month of utero-gestation, you would, perhaps, immediately make 
the reflection that you have at hand a means of suppressing the 
hemorrhage as sure as the surgeon's ligature, or Petit's tourni- 
quet, — I mean the tampon or plug — which, filling the vagina, is 
capable of preventing the further escape of blood, by detaining 
between the tampon and the cervix uteri a quantity sufficient to 
form a coagulum, to extend through the canal of the cervix uteri 
into its cavity, offering a complete bar to the further issue of 
fluid from the bleeding vessels of the womb. But, if a woman 
be flooding, not dangerously, and if there be any hope that the 



ABORTION. 529 

flow of blood may be restrained by hemostatic remedies, or thera- 
peutic procedures, it will be unallowable practice in you to em- 
ploy the tampon, since its usew T ould inevitably destroy the mesen- 
teric attachment of the ovum, to so great an extent, as to insure 
its final destruction. 

The force with which the blood, under a strong hemorrhagic 
nisus, is expelled from the interior of the bleeding vessels, is a 
force far superior to that by which the ovum is attached to the 
womb ; and the presence of a tampon, which prevents the escape 
of the outflowing blood, cannot restrain the flow until the embryo, 
and often the placenta, become detached from the gestative wall, 
and entirely encompassed by a coagulum, from which it is pos- 
sible, after the expulsion of the object, to pick out the unbroken 
membranes, as you would take the yolk of an egg from the midst 
of the white. 

Here then, gentlemen, you perceive a great point of duty to be 
determined upon by you in settling your indications of treatment. 
I repeat, that you have no right to destroy the pregnancy, unless 
the woman's condition clearly points out the necessity for so doing ; 
and I freely declare my opinion, that to use the tampon in the 
flooding of abortion, is as effectually to destroy the child, as the 
rupture of the membranes, or the plunging of a stilette into its 
body. 

I am anxious to put you upon your guard upon this point ; I 
trust you will always act up to the principle that you must not do 
evil that good may come. Wherever a clear indication for the 
sacrifice of the tender embryo exists, no evil is done in procuring 
the greater good of the mother ; on the contrary, the act by which 
it is destroyed, is an act in morals as purely good, as the saving of 
a man's life. The lesser in morals must yield to the greater; the 
lesser is always included in the greater. 

It is out of my power, gentlemen, to say how far you shall allow 
the hemorrhage to proceed, before interfering by means of the 
tampon. This is a point which is to be determined in every spe- 
cial case ; it cannot be determined from any book written by any 
man. It cannot be determined, because no man can say to what 
extent a uterine hemorrhage may proceed, without destroying the 
life of the woman. 

As a general, rule, if a woman not advanced beyond the fourth 
month, loses a teaspoonful of blood, it is probable that she will 
34 



530 ABORTION. 

miscarry ; and yet, not unfrequently exceptions are met with of 
persons who previous to the fourth month, lose many ounces, so 
much in fact as to produce paleness and lipothymia, and yet, after 
the cessation of the hemorrhage, find the pregnancy to go on as 
pleasantly and as regularly as if no such accident had happened. 

It is not your province to decide upon mere probabilities. You 
cannot know in any case of early abortion, whether the embryo 
be living or dead at the time of your arrival; you cannot deter- 
mine this point, for the double sound of the foetal heart, your 
only ground as to a knowledge of its state, cannot be heard so 
early. You need feel no embarrassment on account of this un- 
certainty, since the principle which should guide you, must be 
this, namely, that not knowing it to be deprived of life, you are 
always to consider it as still existing, and as claiming your con- 
servative protection, as long as the mother's interest and safety 
permit its claims to be heard. 

An attack of uterine hemorrhage in the early stages of preg- 
nancy invariably excites considerable trepidation and alarm, and 
the physician is sent for with the most urgent appeals for speedy 
attendance. Upon arriving at the scene of such occasions, the 
first object is to get rid of all the moral excitement, which is 
effected by a calm, dispassionate, intelligent conduct — the nerv- 
ous system becoming free to play its part among the organs, when 
the excitement and disturbance which has become developed in 
it, by powerful moral causes, shall have been allayed. In general, 
it is not difficult to convince the patient, however ill, that the 
physician has power over the case to control it — to handle it at 
will. 

I have sometimes said to persons who I have found frightened 
half to death! "Are you frightened?" and when the reply has 
been in the affirmative, I have continued: "Well then, look in 
my face — look right into my two eyes. Do you see me? and do 
you think that if I were presiding over a case in which a life so 
important as yours was in danger, I should be so utterly uncon- 
cerned as you see me ? Or, will you not take my assurance, that 
it is within the power of any intelligent physician to put a definite 
stop to this loss as soon as it shall, in his judgment, become expe- 
dient to do so? Or, will you believe me a person ignorant of my 
art, and on that account distrust me? Be calm. Be tranquil. 
Be obedient. Be still. — And I shall take good care of you. Do 



ABORTION. 531 

you understand me?" "Yes, sir." "Do you believe me?" 
"I do indeed!" 

Having disposed of all the alarm and trepidation, the next thing 
to be done, is to determine, if possible, the amount of blood that 
has been lost; to which end, you should ask the nurse or attend- 
ant for an opportunity to examine the napkins, sheets, &c, that 
may have been soiled ; besides ascertaining by inquiry the amount 
of what has been thrown away. Don't take anybody's word on 
these occasions, if it be in your power to depend upon your own 
observation. I am very sure, that I allowed a poor woman, many 
years ago, to lose her life, because I neglected this rule ;, having 
trusted to the report of an ignorant nurse, and there are few nurses 
that are not ignorant on these subjects. 

If the flooding is still in progress, ascertain its rate. Take a 
clean napkin, and having crushed it in your hand, in order to 
take out the hardening, let it be applied to the external genitalia; 
taking good care not to allow it to be soaked in a pool of blood 
which has, perhaps, been already effused. Leaving it some ten 
minutes, more or less, in situ, cause it again to be presented to 
you, so that you may judge of the amount of the stain. Should 
the woman have dipped it in a pool of blood, she will present it 
to you thoroughly soaked, though the woman have in the mean- 
time not lost a drop, and thus you may form a determination fatal 
to the life of the young embryo. I beg you, then, not to neglect 
this not trifling caution. 

See that the woman be properly placed. If the day is warm, 
and the bed be situated quite out of the draught of the windows, 
or in the angle of the two walls — let it be conveyed into the centre 
of the apartment, where it is accessible on all sides, and where 
the woman will respire a purer air. If she be weak, don't allow 
her head and shoulders to rest upon pillows; if she be very weak, 
don't let her have any pillows at all under her shoulders, and if 
her strength be exceedingly reduced, take the pillow T s from under 
her head, even if she should lie upon an absolute horizontal plane. 
A haemorrhage that would go on ad deliquium, will often cease by 
taking all the pillows away, because, the momentum of the blood in 
the vessels from which it escapes, is highly favored by its gravi- 
tating power. Sometimes, in excessively dangerous debility 
from hemorrhage, you should not only take away the pillows, 
allowing the head to lie upon the plane mattress, but the feet of 



532 ABORTION. 

the bedstead should be elevated four or five inches, by placing 
some books or blocks under the lower bed-posts. You have thus, 
all the advantages derivable from position, a term in surgery of 
which you doubtless comprehend the meaning and import. 

Muscular contraction is promoted by the influence of cold; 
and the womb, when contracted by the tonic action of its muscular 
fibres, will not bleed so freely as if it remain in a relaxed con- 
dition. Apply cold, then, to the hypogastric region, to the groins, 
to the external genitalia, and to the inner surfaces of the thighs. 
Cold spring or well water, or iced water, should be mixed with 
a portion of vinegar, which is always at hand in every house ; or 
with some spirituous liquor. A large napkin, carefully and 
powerfully wrung out of the cold liquid, should be spread over 
the parts just mentioned, and above it a piece of oiled silk, or a 
square of flannel, to prevent it from wetting the bed clothes, or 
night dress of the patient. 

She will probably be very thirsty, if she have lost a considerable 
quantity of blood, and should, therefore, be provided with very 
cold lemonade, or she should take from ten to fifteen drops of 
Elixir of Vitriol, in a wineglassful of water or a wineglassful of 
filtered infusion of roses, made as cold as possible ; the dose to be 
repeated every hour, or even every half hour, pro re nata, as long 
as the indication for its employment continues. 

Or, we should take some of the alum and nutmeg powder, which 
I mentioned in a former letter ; say, five grains of alum with three 
grains of nutmeg, mixed in honey, or syrup, or any convenient 
vehicle; the dose to be repeated every hour, or half hour, 
according to circumstances. Or, you may resort to the haemo- 
static power of opium, which by its influence over the nervous 
system, whether in the brain or the distal fibril, may have power 
to quell the nisus haemorrhagicus. 

Or, you may give your patient two, three, or even five grains 
of acetate of lead, mixed with one-fourth, one-half, or even a 
whole grain of opium, the dose to be repeated from time to time, 
perhaps not oftener than once in two hours. Beware, however, 
of the sugar of lead ; there is no little danger of determining by 
its use the most obstinate vomiting, or the establishment of the 
whole series of morbid actions denominated colica pictonum. 

A physician is scarcely pardonable who, in a considerable case 
of uterine hemorrhage, fails to explore the condition of the os and 



ABORTION. 533 

cervix uteri. Such an exploration reveals to him the fact of the 
dilatation, or non-dilatation, or the disposition to dilatation of the 
part. If the os uteri be dilated already, the question as to the ovum 
is already decided — it must be lost, and it is no longer deserving of 
our respect. Such a dilatation indicates the use of the tampon, 
if anything be indicated, beyond mere hygienic interposition. It 
is far preferable to any therapia, because, it does not and cannot 
do any harm, whereas all the other procedures which I have 
above indicated are, to a certain extent harmful, saving only, the 
position, and the directions about drinks. 

More than half of the physicians of the United States, probably, 
have the most incorrect notions of the uses of the tampon. I have 
seen those among them whom I esteemed excellent accoucheurs, 
make use of a bit of sponge no bigger than your thumb, and which 
absolutely floated free in the midst of the vagina dilated to the 
size of an immense fist ; for in all these hemorrhages, although 
the sphincter vaginaB may close the ostium, the inner or uterine 
portion of the tube is always found to be extraordinarily relaxed, 
and its walls vastly extended, by the pressure and distension of 
the coagula, which they have at some stage contained. 

Please, gentlemen, to look at the letter, number XXXIII., page 
431, in which I have already given my opinion of the choice of the 
material, and the administration of this useful chirurgical means. 

There is one point which is deserving of your careful remem- 
brance, and that is, the importance, nay the absolute necessity, 
of great care to avoid losing the proofs of a miscarriage. 

A woman does not always recover as soon as the ovum is dis- 
charged ; on the contrary, the irritation of her constitution occa- 
sionally becomes still greater after the womb has become emptied, 
and if you don't know that it has become emptied, you are left 
entirely at a loss for the means of diagnosis. Don't you perceive, 
that if the diagnosis should be that the womb still contains the 
ovum, or a rest of the ovum, your treatment will be founded upon 
that very presence? Whereas, if the diagnosis should prove to 
be that of an emptied womb, your treatment would necessarily 
take some other form ? Some of the most dreadful miscarriages 
that I have ever met with, have been those of very early ova. 
But, if the ovum should not be larger than a black walnut, and be 
contained in the cavity of the uterus with an undilated cervix, its 
accesibility to any information except that derived from rational 



534 ABORTION. 

inference is impossible. As long as it remains there, it is fair to 
regard it as the cause of the mischief, but cannot be so deemed, 
when it has come away. 

Now, if your nurse or the patient herself, upon discovering the 
discharged ovum, should throw it away, how are you to tell 
whether it has been thrown away or not, since, out of one thou- 
sand women, you will not find two and a half that could tell the 
difference between an early ovum and a clot of blood. 

I have had clots of blood sent to me from very good doctors, for 
dissection and for preparation for my museum, under the suppo- 
sition that they were the organized products of a regular fecunda- 
tion. I have had a patient who had been be-deviled for three 
months by an eminent practitioner, under the supposition that she 
was laboring under menorrhagia, whereas nothing was the matter 
with her, but a dead and undischarged ovum. Look at the dia- 
logue at page 241. 

I have told you before, and I tell you now again, that the pro- 
duct of conception may carry on its development for two, three, 
or four months and then die, and remain in the womb without 
exciting the least apparent tendency to contraction, for three, four, 
yes even for six months. Of course, you will not be surprised to 
find that where the muscular irritability of the womb is not excited 
by its presence, there may be, nevertheless, irritation produced, 
and the most probable form that the irritation will assume, will 
be that of the nisus hemorrhagicus. 

Let me advise you again, never to take a woman's report as to 
the organic character of the substances discharged in an abortion 
or miscarriage, but make it an invariable rule of your art, to in- 
stitute careful inquiries as soon as you take charge of the case, as 
to all such appearances as may have been antecedently noticed, 
and to give the most particular and even solemn cautions, as to 
removing or throwing away any such as may afterwards appear 
during your administration of the case. 

A man w T ho has charge of a case of abortion, in which he can- 
not decide whether the abortion has taken place or not, is at sea 
without oars or sails — he does not know w 7 hat to do ; in fact, he 
is like a bull in a china shop. I admit that he might back out 
without breaking the crockery, but he can scarcely turn without 
doing mischief. 
You see I speak feelingly upon this point, and I do speak feel- 



ABORTION. 535 

ingly, for I bear in my memory, the recollection of a case I at- 
tended here a few years since, in which I exhausted all the means 
of diagnosis without being able to come to a conclusion, while the 
patient was visibly drawing nearer and nearer to the brink of the 
precipice. She did not go over, gentlemen, but she recovered 
her health, and I have never yet been able to find out what be- 
came of the ovum, or why she continued after its discharge — if it 
was discharged — to have the same symptoms as those have in 
whom it has not been discharged. 

You should, therefore, claim the privilege, which is justly yours, 
of inspecting with your own eyes all the uterine products, whether 
linen, coagula, shreds or solid substances. It is very clear, that 
when you have got a whole ovum unruptured in your hand, it 
is out of the woman's womb ; and no doubt can rest on your 
mind ; and if she continues sick after this, the diagnosis has lost 
all its difficulty. But, with a perfect diagnosis what do you want 
more ? 

If the process of throwing off the ovum has gone to a certain 
extent, you will find it in the cervix, and perhaps with a large 
portion of it protruding below the os uteri, but still firmly held in 
the grasp of the tube, and keeping on foot those irritations of the 
whole nervous constitution, that serve to keep up the vigor of the 
hemorrhagic effort. If you make such an examination and find 
the ovum protruding, you should place the patient with her 
shoulders upon the same plane with her hips. Direct the nurse 
so to arrange her dress, that there may be but one, and that the 
thinnest of her garments, interposed between your hand and her 
hypogastrium. Let her be upon the right side of the bed near 
the edge. There standing on her right side, press the palm of 
your left hand upon the hypogastric region, so as to push the in- 
teguments gradually and strongly down upon the plane of the 
superior strait, which will bring the os uteri as near as may be 
to the ostium vagime. And now let her draw up both her feet 
close to the buttocks. If, while so situated, you carry the index 
finger of the right hand to the os uteri, it will not recede from the 
pressure, being maintained in situ by the pressure of your left 
hand upon the hypogastrium. The index can now be gently in- 
sinuated betwixt the protruding ovum and the wall of the canal 
of the cervix, and carried high enough in some cases, completely 
to command the product; for if the finger be a little flexed at its 



536 ABORTION. 

last phalanx, the ovum may be caught upon it, as upon a hook, 
and turned out of its bed. If upon examining, there be reason to 
suppose that nothing has been left in the womb, you may tell 
your patient that it is probable that she will have no further 
trouble; or you may go so far as to say that she is well already. 

Where you cannot command it with the finger, you may some- 
times succeed in extracting the ovum, or its rests, by means of 
Dr. Dewees' placenta-hook, or by Mad. Boivin's pince a faux 
germe, or by my friend Dr. Henry Bond's placenta forceps, 
which you can get here, as manufactured by Messrs. Rorer, 
Schively, and other surgery Cutlers. I advise you, though, to be 
well upon your guard against the use of instruments in these 
cases. If you get hold of such a body with an instrument, 
you will be tempted not to let it go again, and if you pull too 
hard, you do so at the expense of tissues that are already in trou- 
ble, and will not kindly submit to any rude handling. I have 
seen a patient severely hurt by the violent extractive force that 
was applied by means of a wretched placental forceps, for the 
extraction of a dead ovum. 

It is even better to wait and trust to the maceration, and the 
discharge in solution or fragments, of the ovum, than to wound or 
tear the organs. 1 have waited in cases where I had failed in 
any reasonable extractive effort; and have found the product 
to be wholly discharged as it macerated, without any other in- 
convenience than that occasioned by the tedious confinement, 
and the offensiveness of the odor. I have no idea that the patient 
is exposed to considerable hazard by this expectant mode of 
treatment, which leaves you with the daily, nay hourly, expecta- 
tion that the uterus will at last wake up to a sense of its condition, 
and free itself from its burden by the exercise of its expulsive 
power. At any rate, an examination, repeated from time to time, 
will make you acquainted with any progress that may be had in 
the expulsive action of the womb ; so that you may have the plea- 
sure at last of picking it out of the cervix, conscious that you are 
doing no injury. 

I had a patient who, in two successive pregnancies, allowed 
the ovum to die between the third and fourth month. In one of 
them, it lingered for several months within the cavity of the womb 
before the organ became irritated to its expulsion. In the other, 
I was employed in the case, and having satisfied myself that there 



ABORTION. 537 

was a dead ovum in the uterus — notwithstanding the woman had 
neither hemorrhage, nor pain ; nor any discharge indeed — I deter- 
mined to try the power of ergot in the case. I gave her a drachm 
of the powder mixed in six fluidounces of cinnamon water, with 
directions to take a tablespoonful three times a day. Before she 
had finished the quantity, the uterine contractions were established 
and the ovum expelled without accident, or any consequent dis- 
order. 

Ergot will often excite the contractions of the uterus in the 
early stages of gestation, but it is often found utterly to fail in the 
exertion of its peculiar therapeutic powers. But, as no inconve- 
nience is to be apprehended to the health from its administration, 
you should consider yourselves at liberty to employ it in fulfil- 
ment of a clear indication. The wine of secale given in tea- 
spoonful doses, and repeated from time to time, according to the 
exigencies of the circumstances, will be found a convenient and 
often an effective administration ; and I presume you would not, 
in any case of serious hemorrhage or protracted retention of the 
product, fail to put into play its extraordinary power over the 
muscular organ of the womb. 

A woman who has miscarried, if no accident follow the event, 
will be likely to get rid of her lochial discharge in the course of 
a few days. It often disappears on the third day, but sometimes 
continues to the tenth, or twentieth, or even longer. 

When the woman seems recovered, she thinks she ought to 
have the privilege to get up and take care of her affairs, or give 
herself up to her pleasures; but she will be highly imprudent to 
do so, nor will you fulfil your duty as medical counsel, if you ad- 
vise or allow her thus to expose her health. She should be kept 
very quiet for many days, during the greater portion of which, 
she should be in the recumbent posture, either in bed, or on the 
sofa or couch; nor should she be permitted to go about until all 
signs of miscarriage have entirely disappeared. 

A miscarriage within the first four months is not followed by 
secretion of milk from the mammary gland ; but, should it go to five 
months and a half, before she loses the ovum, the woman is very 
likely to have an abundant secretion of milk. I attended a poor 
woman some years ago in Tenth street, who miscarried at five 
months and a half, and soon after, she became a wet nurse, at my 



538 ABORTION. 

request ; having a supply of milk sufficient to support a strong 
healthy child. 

A woman who has suffered one abortion, is probably more 
liable to the same accident in subsequent pregnancies, than she 
who has not suffered in this way. 

There are many persons who suffer repeated miscarriages, and 
whose health is injured by the irritation and loss of blood accom- 
panying the accidents; moreover, the disappointment experienced 
in regard to the hopes of offspring, occasions great disquietude ; so 
that it is extremely desirable to discover some method of obviating 
such an evil tendency. I have no doubt, as I before expressed, 
that in these cases the mensual effort is often at the foundation of 
such distressing occurrences ; for women are more apt to mis- 
carry at stated periods than at irregular times. Many of the early 
embryos that I have met with, have been so fresh and so firm in 
their texture, that I could not but suppose them cast off while still 
endowed with vital properties. Under such circumstances, I 
could not but suppose that the accident of the casting off of the 
uterine product, was the result of a status of the womb itself, and 
not of the ovum. 

I supposed that the ovary might have deposited a mature ovum, 
and that the uterus, obedient as usual to the provocative sanguine 
affluxion, became, as usual, mensually engorged, which resulted 
in the effusion of mensual blood at the expense of the attachments 
of the embryo, which began immediately to be cast off, and thus 
came into my hand, fresh, firm and recent, as above mentioned. 

It is true that many causes of abortion besides this mensual 
cause do exist, — a blow, a violent succussion or shock, an irrita- 
tion of the womb consensual with intestinal irritation, some deep 
emotion of the soul, modifying the relation of the innervative 
forces of the whole constitution, alone, followed by sudden reaction 
in the force of the arterial injection; may well determine an in- 
stant polygsemia of the uterus, to be relieved only by an effusion 
of blood from its internal wall, at the expense of the mesenteric 
attachments of the embryo. 

I had, some time since, a very perfect specimen of an ovum 
of two months and a half, which came off enveloped in the de- 
cidua. Having opened it, and placed the little embryo on the 
field of a Wollaston doublet, in order to inquire into its condition, 
I found that it had suffered from an apoplexy of its cord, for one 



ABORTION. 539 

of the omphalo- mesenteric arteries had given way and filled the 
tissue with extravasated blood. Probably myriads of young em- 
bryos perish from the delicacy of their organism and the feeble- 
ness of their vital forces. For, notwithstanding they are so care- 
fully and perfectly protected by the beautiful nidus in which they 
reside, which nidus itself is supported as it were upon the most 
elastic springs to save it from shocks and violent succussions, they 
must be deemed liable to the hazard of multitudinous derange- 
ments of their circulation and innervation, fitted to lead to their 
destruction. 

There are also numerous women to be met with, who cannot 
carry the gestation out beyond a certain time, not absolutely fixed, 
but yet far short of full term. Their children always die, and 
they know that the child is dead, in the first place, from the 
absence of all spontaneous motion and from shrinking of the before 
well developed breast, and from a certain sense of heaviness, or 
sluggishness or strange ponderosity within. The womb, more- 
over, seems to fall from right to left, or from left to right, as the 
woman happens to turn from either of these positions. I have at 
this moment a woman under my care at the Pennsylvania Hos- 
pital, who has lost many children at about the sixth month. 
These children were always born dead, putrid, having remained 
from four to six weeks in the womb after the cessation of their 
existence. She applied to me for admission, informing me that 
the child was dead as usual, an opinion in which I concurred 
after careful auscultation, and which was confirmed by the birth 
of the child, after it had remained a month dead in the womb. 

If you ask me, my young friends, why it is that these women 
lose their children in utero so repeatedly, I feel that I shall be 
compelled to say that I cannot give you any explanation of this 
strange occurrence. They do not, so far as I know, appear to 
suffer from rigidity of the uterine texture, contravening its natural 
expansibility under the growing force of the ovum ; nor have I 
discovered in them any signs of general or topical ill health, save 
the one in question, if indeed that be one. It is most likely, I 
think, that the fault exists in the ovum itself, for I think it is not 
unphilosophical to suppose, that a woman may be possessed of 
all the signs of competent health in her own person, whereas, the 
ova which she produces may be weak, and unendowed with the 
usual amount of vital force. But it is vain to form or utter hypo- 



540 ABORTION. 

theses ; it is better to say on such occasions, we do not know, we 
do not understand. 

A lady under my care, gave birth to a son at full term ; after 
which, she was sixteen times pregnant in vain; sometimes going 
to the seventh month and giving birth to the child dead, putrid ; 
and sometimes going to the fifth, fourth, or third, and always suf- 
fering so great an amount of constitutional disturbance during 
pregnancy, and also sustaining so great loss of blood during 
the abortion, as to leave her at the last in a state of wretched 
health, consisting mainly in disorders arising from repeated, ex- 
cessive anaemia from hemorrhage. When she came under my 
care, after the sixteenth pregnancy, for the first time, I gave her 
directions which she carefully followed, and carried the child a 
little beyond the eighth month, when it was safely born. Another 
pregnancy, within two years, was followed by the birth of another 
son. When this child was between two and three years old, she 
died instantly of apoplexy while seated at her dinner table. 

Doubtless, miscarriages often depend upon irritability of the 
womb, w T hich refuses to dilate under the pressure of the growing 
ovum. The Hallerian irritability of the womb, or its muscular 
contractility, may be so great as to repress the advance of the 
ovum in growth. If you had such an ovum growing inside of a 
metallic sphere, it would necessarily die, because it is indispensa- 
ble for the embryo not only to live, but to grow, for its life does 
not consist in living but in developing itself. But, if the womb 
won't let it develope itself, will it not die ? and hence, don't you 
perceive that an unyielding, rigid uterus may cause the woman 
to miscarry again and again, whereas if you cure the rigidity and 
unyieldingness of the womb you may allow the woman to go out 
to the full term of utero-gestation ? 

Suppose you were treating a case, taking such views as these 
as to the cause of the miscarriage, what could you do to give the 
uterus a kindlier disposition? Could you not obtund its organic 
sensibility and at the same time diminish the vital force of its 
motor nerves, by bringing it occasionally, at proper intervals, under 
the sedative influences of opium, and under the relaxing influ- 
ences of venesection, of the warm bath, and of a cool and light regi- 
men? Could you not give to such a patient at bedtime five-and- 
forty drops of tincture of opium mixed with a wineglassful of thin 
boiled starch, to be used as an injection into the rectum? I have 



ABORTION. 541 

done so for a great many people, for a great many years, when I 
have deemed the cause of the disposition to miscarry, a cause 
connected with the status of the womb itself. I shall probably as 
long as I continue to practice, frequently employ this method, as 
I have every reason to believe that a great many persons have 
thereby been preserved from miscarrying, who have repeatedly 
done so under every other mode of treatment. 

I have occasionally directed such an administration to be re- 
peated both night and morning, and it is as a sort of general rule 
with me, in giving such a direction, to counsel the woman to use 
the anodyne enema daily, until after the quickening of the child 
takes place. I know of no objection to such a mode of pro- 
cedure, as I have never found the least inconvenience to result 
from it as regards the patient's health. Taking it all in all, as a 
methodus medendi, it is the most commendable one that I am 
acquainted with ; it was Doctor Physic's, and I learned it from 
his lips. Dr. Physic had very few methods that were not to be 
depended upon ; and the sanction of his opinion alone, would, in 
my estimation, make it worthy of the highest confidence. 

If a woman is likely to miscarry from her menstrual cause, she 
might be confined to her bed at the menstrual period, a little be- 
fore, during, and for a few days afterwards. Her bowels should 
be kept free by gentle aperient medicine, or by enemata, which 
are less objectionable, as causing less disturbance; she ought to 
be bled, not too much, but moderately, at the arm, with a view to 
counteract the monthly engorgement of the uterine and spermatic 
branches ; an intention, which will be well sustained by the daily 
use of the anodyne enema, as before mentioned. 

A woman might be supposed to miscarry in consequence of 
debility; in such a case, the use of proper tonics, with nutritious, 
wholesome diet, should be carefully prescribed. 

Don't give a pregnant woman purgative medicines, if you can 
possibly avoid it; since violent action of the bowels, particularly 
of the lower bowels, is extremely apt to bring the womb into 
sympathetic disturbance. 

Women have the toothache in pregnancy, and will come to you 
to ask permission to have the tooth taken out. You should 
always decline to give your consent to this operation; an opera- 
tion, which cannot be performed, I think, without producing a 
dangerous shock to the nervous system, and violent succussive 



542 ABORTION. 

contractions of the diaphragm and abdominal muscles, quite as 
apt to disturb the connection of the ovum with the womb, as a 
fall, a blow, riding in a carriage, or any of those causes which 
physicians are so careful to guard their patients against. If a 
woman have in her pregnancy an insufferable toothache, you will 
often cure it by putting a couple of leeches on the gum, opposite 
the alveole, or by filling the carious cavity, if there be one, with 
opium, or it will get well after a few days, if she will but have 
patience with it. I will not deny that a toothache may be so in- 
supportably painful, as to warrant the patient in having it ex- 
tracted, and warrant you in giving your consent thereto ; but 
let me advise you never to do so, when you can find any rea- 
sonable ground for avoiding it. 

Some physicians, when a woman applies for counsel for this 
habitual abortion, always advise her to go to bed and stay there, 
under the idea that motion or exertion is apt to provoke the abor- 
tion in those who are predisposed to it. 

It may be that a woman is safer in her bed, or on her couch, 
than walking about town, or riding in her carriage, or engaging 
in domestic affairs ; and it is palpably true, that a woman who 
perceives some present threatenings of miscarriage ought to go 
to bed, and be still. I cannot but think, however, that sending a 
woman to bed, with the purpose to keep her there until the end of 
her pregnancy, not to be completed until the lapse of six, five, or 
even four months, is altogether preposterous ; since I cannot well 
conceive, that a woman could, for so long a time, be deprived of 
exercise, of fresh air, and of solar light, without inducing modifi- 
cations of her nerve force, and of her nutrition, that would be 
more likely to lead to a miscarriage than the very exercise that 
is so much dreaded. 

I am quite certain, that I have never been guilty of giving so 
preposterous an order as this, and that I have known many in- 
stances in which the practice hath signally failed. I believe, 
indeed, that it would be better for a woman to miscarry than to 
lie down for six months. 

If a man break his thigh bone in the midst of the most con- 
summate health, and if he be taken to his house and laid upon 
his bed, and treated with Dessault's apparatus, or any other ap- 
paratus for the treatment of fracture of the thigh, then he will 
not have his bowels moved, for the first eight days, unless he take 



ABORTION. 543 

some eccoprotic article. His bowels do not become confined be- 
cause he has broken his leg, but they are constipated for want of 
the perpetual succussion, which it is designed they should re- 
ceive from the abdominal muscles which encase them. The man 
with Dessault's splint is like the woman who you put to bed for 
six months, they have neither the least occasion to use the abdo- 
minal muscles in progression, nor in daily exercise, and the ali- 
mentary tube, deprived of this usual provocative to its excitement, 
lies torpid, its muscular fibres scarcely, or with reluctance, per- 
forming their office of provoking motion in the canal. 

In order to obviate this evil, you are compelled to give drugs, 
but a pregnant woman ought not to take drugs if there be any 
means to avoid it, and I think you w T ill find it, upon a studied 
experience, which you will have, that it is best not to place her 
in a condition where your drugs will become necessary. 

To allow her to become costive, is to disturb the whole of her 
splanchnic innervation. She gets a foul breath, a foul tongue, 
and restless nights ; her appetite is mawkish, she loses the bright 
tint of her skin, and masses of the circulation tend inwards, pro- 
ducing engorgement of the greater trunks ; and, if you succeed 
in carrying her to the end of her term, — an improbable expecta- 
tion, — you will deliver her of a child, when you shall have ruined 
her health. 

I mentioned, at page 540, the case of a lady, who had been 
sixteen times pregnant in vain, who, after undertaking my direc- 
tions, gave birth to two children in succession. I said, there, that 
w T hen she came under my care, after the sixteenth pregnancy, I 
gave her directions, which she carefully followed, and carried the 
child to the eighth month, when it was safely born. She had been 
repeatedly confined to the sofa, or the couch, during several con- 
secutive months. Several of the gestations w r ere conducted under 
the counsel of the late Professor Dewees, who had great confi- 
dence in protracted repose for the conservation of the gestation; 
but, as in all the cases, she had continued to meet with disappoint- 
ment, when she came under my care, and related the distresses 
of which she had been the victim, I made known to her my aver- 
sion to this treatment by rest. I said to her, "My dear madam, 
you place me in a very disagreeable predicament by appealing 
to me on this occasion. In all probability, seeing your present 
age and your present health, this will be the last of your gesta- 



544 ABORTION. 

tions ; you have heretofore been under the care and the counsel 
of the most distinguished practitioners of my art, in this country 
and in Europe, and it has, perhaps, become a principle with you 
to treat all such cases by profound and protracted rest. If I, 
who am opposed to such a method, should advise a contrary 
course, and the case should result in an abortion, as usual, you 
might hereafter accuse me of great imprudence in departing 
from a method so recommended ; and becoming never pregnant 
again, charge me with depriving you of the last chance of having 
offspring. Nevertheless, I shall guide you according to my judg- 
ment and my conscience. I believe that the best health that 
you can obtain, is the securest health for your pregnancy, and 
that health can only be had by exercise, sub dio, in the open air. 
Pray, then, take my advice, to walk out, or to ride out, daily; 
receive and return visits; go to the party and the ball, and try to 
forget that you are pregnant, acting, indeed, as if you were not; 
be always, however, a little careful of using violent muscular effort, 
or awkward positions of the body; and above all things, do not 
tumble down stairs. Take an anodyne injection every night be- 
fore you go to bed, and let it consist of forty-five drops of lau- 
danum, in half a wineglassful of thin clear starch." 

She did follow my directions implicitly, saving only the ex- 
ception, that she did tumble down stairs twice, and yet, I had 
the pleasure of delivering her of a child, as mentioned at page 
540. 

When I was an apprentice to my late master, Dr. Thomas 
Hanson Marshall Fendal, of Augusta, in the state of Georgia, I 
was acquainted with the circumstances of a case of abortion un- 
der his care. The lady in question, whose name I am bound to 
withhold, expelled an ovum containing a foetus of about three 
months, yet six months afterwards she gave birth to a male child 
at term ; so that it is possible for a woman pregnant with twins, 
to discharge an entire ovum of one of the twins, without destroy- 
ing the mesenteric attachment of the other, which goes on to the 
full term. 

Such a case is so rare a one, that probably, if you live a long 
medical life you will never meet with one like it. It is well, 
however, to know that such things are in rerum natura. 

I have seen one case in which, a woman giving birth to a child 
at full term, afterwards discharged a placenta, attached to which, 



ABORTION. 545 

"was a foetus of four months and a half, completely mummified 
and pressed as flat as a bit of deal. Some stupid people, upon 
such a sight, would lift up their hands and exclaim " superfceta- 
tion!" Superfcetation has nothing to do with it ; it is a case of 
abortion, with retention of the foetus four months and a half after 
its death. 

You will find a beautiful drawing representing a precisely 
similar case, in the tenth plate of the Atlas to Mr. Pouchet's 
" Theorie Positive de V Ovulation spontanee." The account of the 
case is related at page 436 : the child was, as in the case which 
I saw, compressed, its head being mashed flat by the pressure of 
the living ovum against the side of the uterus. 

I think, gentlemen, that for the present I have nothing further 
to say upon abortion ; I have only a few remarks to offer you, on 
the subject of moles or false conceptions, which will suffice for 
the present, to close this subject. 

In ancient times, the doctors were accustomed to have very 
curious notions on the subject of what are called moles; and 
some of their superstitions about them are very curious and 
amusing. 

There is still a vague superstition that lurks in the female 
mind even at the present day, and which renders the production 
of a mole a subject of much talk and wonderment. They are 
called by most people in this quarter false conceptions, and are 
rarely met with without giving rise to much examination and 
cross-questioning, addressed to the medical attendant. They who 
have had a false conception, or a mole, are anxious to know why 
and how such a thing happens. Not only have I found the 
female worried about such an event, but I have also discovered 
that the husband is not without some uneasiness and self-condem- 
nation. It happens in this way. 

When a woman conceives in the womb, she goes on in her 
pregnancy for some weeks, or for two months, perhaps, perfectly 
well and naturally — the embryo then perishes, and floating in the 
amniotic waters, undergoes a process of maceration and solution; 
so that it soon disappears completely, leaving a brownish dirty 
liquor still enclosed within the amnios. 

The spongy or tufted chorion, having in the mean time estab- 
lished a mesenteric connection with the uterus, a sort of vitality 
continues to exist within it, provided the womb does not cast it 
35 



546 MOLES. HYDATIDS. 

out by contracting its walls. — Under this low rate of life, the mass 
of the mole slowly increases in size, and becomes more and more 
solid and heavy. The mass continues to grow more or less 
rapidly, until the womb, no longer able to tolerate its presence, 
contracts, and expels it. 

Such a mole is but a diseased and altered ovum — and the 
woman who is distressed with the notion that she has some pecu- 
liarity of nature that concerns her, the subject of such a misfor- 
tune, ought to be relieved of the false impression, which might 
render her unhappy. 

Sometimes the ovum, instead of being converted into a firm, 
hard, and fleshy substance, becomes the seat of what is called 
hydatids of the womb. — In this case, every part of it is occupied 
by numerous vesicles of various sizes, from the bigness of a mus- 
tard seed to that of a large Malaga grape. These vesicles are 
filled with pellucid fluid — and they continue to be formed and to 
increase in magnitude until the womb acquires the dimensions of 
the gravid uterus of the seventh month. Or, the womb irritated 
by the pressure of such a foreign body, refuses any more to dis- 
tend, whereupon, contractions setting in, the whole heterologue 
product comes away, in quantity, sometimes, sufficient to half fill 
a wash-basin. 

It is asserted by some writers, that the grape-Zz&e vesicles are 
really independent animals — acephalocysts, endowed with great 
powers of production ; but I am by no means of that opinion. 
They are, far more probably, derived from the distension of the 
altered spongioles and cellules of the placenta, which, by some 
endosmosic act, become filled with water, and thus dissect, so to 
speak, the whole mass of the mole or the altered placenta. 

Now and then, you will meet with cases, where the child being 
born in good health, the placenta exhibits numerous specimens of 
these bullse. If very numerous, they could not fail to destroy the 
embryo, by destroying more or less completely its branchial organ, 
the placenta. 

A case is not, in general, suspected of being a false con- 
ception, and it is not until it is cast off that the truth is known — 
still, when the pregnancy proceeds at a more rapid, or at a less 
rapid rate of development than natural, and when the woman is 
troubled with the frequent slight markings and discharges of blood 
per vaginam, she may be held as suspected. 



MOLES. HYDATIDS. 547 

The rapidity with which a bunch of hydatids may grow, is 
very great. I have, for example, now under treatment a young 
lady, married about a year ago, w 7 ho became pregnant about the 
20th July, 1847. On the 23d October, 1847, she discharged a 
large quantity, near a pint measure, of hydatids and altered pla- 
cental structure. 

Pending the gestation, she was sick for twelve weeks, during 
a major part of which time she vomited daily, and many times 
a day. She became rapidly and excessively emaciated, and had 
for a long time a pulse above 120 per minute. Previously to the 
expulsive effort, the fundus uteri had risen nigh to the umbilicus, 
and yet she was only three months gone, at w T hich period the 
fundus ought not to have jutted much above the plane of the su- 
perior strait. 

The womb was always of a doughy feel, except when con- 
densed by its muscular contraction, which was often the case 
during the process. 

My fears w r ere greatly excited by her condition, until her pains 
coming on, the whole diseased mass was driven out of the uterine 
cavity — whereupon she immediately began to recover, and is now, 
Nov. 6th, 1847, in pretty good health, although still weak and 
pallid. 

If you should take charge of a patient, pregnant, sick, suffer- 
ing occasional attacks of uterine hemorrhage, with great con- 
stitutional irritation, evinced by frequency of pulse, emaciation, 
and other signs of suffering — and if coincidently with such signs, 
there should be a too rapid development of the womb — you might 
very confidently make the diagnosis of hydatids. Because, in 
true pregnancy, the rate of development is decided by a generic- 
law — peculiar to each genus of animals — or to each species 
rather. If the rate of growth is non-generic, the product will be 
non-generic likewise, and leave you clearly at liberty to take 
measures for the cure. 

In such a case, you cannot bring on premature labor — but you 
can bring on labor. There can be no prematureness for a thing 
that has no generic term of development. You might provoke 
contractions of the womb by doses of ergot, or if that should fail, 
by the use of sponge tent carefully placed in the canal of the 
cervix uteri. A sponge tent could hardly expand in the canal, 
without causing the fundus to enter into active contractions. 



548 LYING-IN DISEASES. 

There are some women, in whom the womb, during menstrua- 
tion, becomes filled with small coagula. A coagulum of blood as 
large as a walnut, in the non-gravid uterus, would be subject to a 
firm pressure ; the serum escaping, might leave the more solid parts 
within the cavity, which might remain therein undisturbed during 
an intermenstrual period. New coagulations taking place at the 
return of the menses, the mass becomes increased in size, and at 
last exciting contractions, is expelled, with the sharpest grinding 
and dilating pains. 

I have seen a lump of fibrine larger than a black walnut, ex- 
ceedingly solid, and of a whitish yellow color, produced in this 
way.^ 

It is not a false conception — but a lump of fibrine, out of which 
all the serum and corpuscles have been squeezed, and which may 
lie a longer or shorter time in the womb without exciting its ex- 
pulsive power — and at last come off with very violent grinding 
pains — so great, indeed, as to make the woman suffer as much as 
in the most painful miscarriage. 

I shall here close this letter, with the expression of my sincere 
respect. C. D. M. 



LETTER XL. 

Gentlemen: — I am about to address you to-day upon a sub- 
ject of the extremest importance in any consideration of female 
complaints. I mean the diseases of the Lying-in. A treatise on 
midwifery might be, perhaps, more appropriately selected for 
such a discussion, — but, inasmuch as the general practitioner is 
liable to be called upon for his counsel in many of the purely 
puerperal affections, he ought to be as well prepared as the ac- 
coucheur himself to treat them properly. 

Among the earliest and most serious of the disorders of the 
puerperal woman we should enumerate fainting and flooding. 
They generally go together, — so much so, indeed, that when a 
woman faints away shortly after the birth of her child, she should 



LYING-IN DISEASES. 549 

be immediately held as suspected of flooding, — whether there be 
any visible hemorrhage or no. 

It is true, however, that a woman may faint immediately after 
the delivery of the child, and yet not be the subject of any con- 
siderable hemorrhagic discharge. This accident is most likely to 
occur to women in whom the womb has been excessively dis- 
tended, either with a twin pregnancy, or from the accumulation 
of a great quantity of the amniotic liquor. Such a person, having 
a very rapid labor, and speedy discharge of the after-birth, is 
likely to faint for want of a due amount of pressure upon the ab- 
dominal viscera. The same thing happens to those who are re- 
lieved, by tapping, of a large ascitic collection. 

I was present a few years ago, when Dr. Jacob Randolph, of 
this city, tapped for me a young woman who had a vast ovarian 
cyst. A broad bandage, or binder, was put, as usual, around the 
abdomen, to be drawn tighter, in proportion as the water of the 
dropsy should run off through the canula. When rather more 
than half of the fluid had escaped, and the abdominal walls had 
lost much of their tension, I purposely relaxed the pressure of the 
binder, which I had taken by its ends in my hands. As soon as I 
left her solely to the pressure and support of her own abdominal 
integuments, she grew faint, but immediately recovered upon my 
tightening the bandage again. This experiment I repeated seve- 
ral times during the progress of the operation, with a view to 
satisfy my mind as to the relation between lypothymia and re- 
laxation of tegumentary tension. 

A woman whose abdomen becomes very suddenly and greatly 
reduced in size by the escape of a full-sized child — a great quan- 
tity of waters, and an after-birth of more than a pound in weight, 
suffers, then, the same sudden withdrawal of abdominal tension 
as the patient under paracentesis, and requires, like that patient, 
the support of a bandage, or binder, adjusted to the abdomen. I 
published in the Philadelphia Pract. of Med., 2d ed., p. 204, a 
case, which is related in the following words: — 

I attended Mrs. J. A. S., confined with her fifth child, in a 
labor that was perfectly natural relatively to the birth of the child, 
the delivery of the placenta, and the symptoms that immediately 
ensued the parturient state. 

Having waited about half an hour, I took leave of the patient 
about two o'clock in the morning, and had proceeded a good way 



550 FAINTING AFTER DELIVERY. 

towards my house, when I was overtaken by the husband, who 
entreated me to hasten back to the lady, as she seemed near 
dying. 

Upon returning to the house, I found my patient without pulse; 
the face of an extreme paleness, and her whole state expressive 
of the last degree of sinking or prostration. The idea that became 
immediately obvious was, that she must have had a large effusion 
of blood ; but, upon placing the hand upon the uterine region, 
the organ was found to be well condensed ; while, upon a careful 
examination of the bed, no very considerable extravasation of 
blood was detected. I found that the abdominal parietes were 
remarkably flaccid; to such a degree, as to strike me forcibly, as 
affording incompetent support to the viscera within. Indeed, the 
contractility of the abdominal muscles was so very slight, that it 
appeared to me the bowels could receive almost no support from 
their pressure. 

After exhibiting such restoratives as were at hand, I folded two 
large towels into squares, and placing them upon the abdomen, 
as compresses, secured them by a bandage, which retained them 
in situ, and afforded such a degree of support to the contained 
viscera as I deemed sufficient to obviate the sinking and fainting 
tendencies that always ensue from a loss of this support or pres- 
sure. I enjoined rest in a horizontal position, removed the pillows 
from under her head, and found, when the forces of the consti- 
tution had rallied, there was no further alarm or distress. It 
has happened to me many times to meet with this syncopal state, 
after delivery, unaccompanied with hemorrhage, either external 
or internal ; and in all parturient persons who are enormously 
distended, or who are prone to such faintings after delivery, I 
take the precautions suggested by the above case in good time ; 
and I can safely say that such precautions generally result in 
success. 

Fainting is caused by diminished tension of the blood-vessels 
of the encephalon suddenly produced, whether a pathemate mentis, 
or hemorrhage, or other causes. There can be no such thing 
as fainting with the vessels of the brain full and tense. If you 
suddenly take away the support — I mean the extrinsic support 
that the great arterial and venous trunks, as well as the arterioles 
and venules and capillaries of the belly receive from the muscu- 
lar and other textural integuments, you suffer those vessels to 



FAINTING AFTER DELIVERY. 551 

yield to the lateral pressure of the blood-columns — to become dis- 
tended, and thus draw off the circulation from the superior parts 
of the economy, especially if the patient be permitted to sit up, 
or to lie too highly inclined. See to it, then, that the danger be 
obviated by substituting the bandage pressure for the lost pres- 
sure of the abdominal walls, — and that the patient be not allowed 
to sit up, or even have pillows, where the case requires such a 
precaution. 

I ought now to put you on your guard against a mistake into 
which you might fall, were you to be governed in some cases by 
opinions like those just expressed. 

You must not believe that the newly-delivered woman faints 
from withdrawal of pressure and tension of the integuments, 
when she in reality faints from loss of blood. 

A woman may lose a quantity sufficient to cause an alarming 
and even a dangerous deliquium, without any visible signs of 
flooding upon the napkins or clothing about her person — and even 
when the globe of the womb appears to be well contracted. 

On a great multitude of occasions, I have found women to faint 
after delivery, say in half an hour, and sometimes in an hour, or 
even as late as an hour and a half, subsequent to the expulsion of 
the after-birth. I have had the napkin immediately presented to 
me for examination, and found it scarcely stained. Upon placing 
my hand on the uterine globe, too, I have found it well reduced 
in size, and firm, and so small, as evidently to contain no con- 
siderable quantity of blood. Were one to trust to such a diag- 
nosis as this, he would, in many instances, make a great mistake, 
supposing that the fainting does not depend on flooding — and 
this is the very error against which you should most vigilantly 
guard yourself. 

Let me explain. 

A woman, after the delivery of the placenta, shall have a good 
contraction of the uterus. She shall have a napkin applied firmly 
against the privities — and suppose herself to be quite well and safe. 
In the course of half an hour, or an hour and a half, she shall ask 
to be fanned, or for some drink, or for the volatile salts, and say 
she is faint. Her pulse will be very small, and feeble, and fre- 
quent — or it may be, undiscernible. The attendant at once 
places his hand upon the hypogaster to discover the state of the 
uterus, which he finds small and sufficiently firm. He ascertains 



552 FLOODING AFTER DELIVERY. 

that there is no visible hemorrhage, and is apt thence to conclude 
that there is no hemorrhage at all. But if he trusts to restoratives 
and cordials, et id genus omne, he may lose his patient — for her 
vagina is filled with coagula in quantity sufficient to make her 
faint away, and even to put her life at risk. 

The vagina is extremely distensible always, but immediately 
subsequent to delivery it remains so dilatable that the slightest 
pressure against its walls makes them yield. It has lately been 
expanded to a dimension sufficiently great to contain the trunk 
of a child's body, which is very large. If the nurse, upon her 
delivery, should clap a large napkin against the exterior genitals, 
and the patient, in. order to keep it there, should strongly adduct 
the thighs, the issue of the lochia would be impeded, or prevented 
entirely — but, even the condensed womb bleeds, more or less; 
and the blood that it sheds, passing into the vagina, and finding 
no issue at the ostium, becomes coagulated. The whole tube of 
the vagina becomes enormously distended with coagula, as large 
as the trunk of a child's body, and the woman faints for the loss 
of her blood. The napkin outside acts as an obturator — and the 
clot inside as a tampon. The lochia cannot find issue — and the 
quantity lost is considerable enough to produce fainting. But I 
have long been convinced that another principle, in addition to 
that mere one of the loss of blood, is concerned in the production 
of the phenomena. I mean to say that the woman will faint for 
the loss of the blood, and continue to faint again and again, pro- 
vided the coagula are not removed from the vagina and cervix 
uteri — but, she will immediately recover from her deliquium, 
upon their removal. There is some influence of a disturbing 
nature, as to the nerve power, that is connected with the presence 
of a large quantity of clots in the vagina — probably that influence 
may proceed from the distension of the walls, and their pressure 
on parts in relation to them exteriorly, and on a nervous im- 
pression they suffer. Be this as it may ; it is quite certain that 
if you should press two fingers of the right hand into the canal of 
the vagina, and w T ith them break the clots to pieces, while, with 
the other hand upon the hypogastrium, you press the globe of the 
w r omb downwards into the excavation of the pelvis, exhorting 
the woman, meanwhile, to bear down, the coagula will all be 
expelled, the vagina will contract its tube, and the woman will 
at once be relieved, and scarce fail to express her satisfaction 



FLOODING AFTER DELIVERY. 553 

with much energy and emphasis. To take out the coagula, or 
" turn them out" as I used to say to you, does not give the wo- 
man any more blood, or replenish her veins, and yet hundreds, 
yes, many hundreds of times have I seen women instantly re- 
cover from the most depressing feeling of faintness and prostra- 
tion, upon turning out the clots from the vagina. Hence, I re- 
peat, that to turn out the clots, is to relieve the patient of her 
deliquium. But, gentlemen, suppose you do not turn out the 
coagula ! why, then, you leave a tampon of clotted blood in the 
vagina! No sensible man would ever think of such wicked folly 
as that. Every sensible, well instructed medical man knows, that 
where the womb is firmly contracted, there is no flooding — and 
that where it is relaxed or uncondensed, it will bleed, and that 
the blood it sheds, will fill its cavity — and distend it more and 
more, in proportion as the blood flows — and not only so, but, the 
larger it becomes, the more rapid is the effusion. The patency of 
the hemorrhagic orifices on the inner superficies of the uterus, aug- 
ments at a certain ratio to the augmentation of the superficies. 
There can be nothing, then, more preposterous than to place a 
tampon in the vagina of a newly-delivered woman, and nothing 
more careless than to leave one there, that nature may have ad- 
justed there in the shape of a clot of blood. 

From all the foregoing it results, that a woman may faint from 
hemorrhage after delivery, notwithstanding that you can discover 
no great distension of the womb, and though there may be no 
external visible signs of a flooding — and the precept that arises 
out of it is this — viz., when you go into an apartment where 
a woman just confined is in a fainting state, your first act of 
duty is to place the hand on her hypogastrium in order to see 
whether the w T omb is any larger than it ought to be; — second, to 
make a careful investigation as to the quantity of blood contained 
in the clothes and bed-clothes about her person ; — and third, 
when the womb is well down and the clothes quite unstained, 
to pass two fingers of the right hand into the vagina and turn out 
the clots if any be there ; and if there be none there, nor in the 
womb, you have a clear diagnostic of deliquium from some cause 
unconnected with a flooding. 

But, a woman shall flood very dangerously, without discharging 
any blood upon the napkins or bed-clothing about her ; and when 
you come to put the hand upon the abdomen in order to inquire 



554 FLOODING AFTER DELIVERY. 

into the condition of the uterus — you shall find that the womb has 
become very large again, and has risen up, so that its fundus 
reaches nearly as high as the navel. This is a case in which, not 
the vagina only, but the uterus also is filled with blood. 

It is worthy of remark that the clot in the womb, in this case, 
always feels very solid : — so much so, in some of the samples, as to 
tempt to the belief that it is not clot, but a large portion of placenta. 
The woman's life is in danger until the blood shall be discharged ; 
and there is no time to be lost, therefore, in taking it away. 
This is to be done by compressing the uterine globe with the 
palm and fingers of the left hand, while with the index and 
medius of the right, or sometimes with the whole hand passed 
beyond the sphincter vaginae, you are empowered to break to 
pieces the solid coagula in the" womb itself. After having first 
got out those that may be detained in the vagina, exhort the wo- 
man to bear down: if she makes a proper effort, while you at 
the same time continue to break up the masses that descend 
within reach of your fingers — the whole will be found suddenly 
to gush forth — the womb will again become hard, condensed, 
solid, and very small — and that is the end of the flooding for the 
present. As soon as the uterus has become thus quite empty — 
you should endeavor to secure a good permanent contraction of 
its muscular fibres, by gently pressing or kneading it with the 
palps of the fingers of the left hand — and this you should do for a 
considerable length f time. You know that not the muscular fibres 
of the womb only, but also those of the bowels may be excited 
to contraction by frictions which serve to arouse and stimulate 
their irritable nature. These frictions, then, are very powerful 
means of keeping the texture of the womb hard and firm ; but if 
the texture of the womb is thus kept hard and firm, don't you 
perceive that there can be no flooding? — since, in that firm and 
contracted condition, the vessels of the womb are crimped and 
constringed, and their lights, in many instances, almost put out. 
Surely you recognize the truth, that the great veins and sinuses of 
the womb, that are seen in it when at full term, are invisible in 
the non-gravid organ. Well, then, when you want to make those 
great veins and sinuses and arteries as small as possible, so they 
may carry as little blood as possible, you will do all you can do 
to make the womb approach, as near as possible, to its non-gravid 
magnitude. 



FLOODING AFTER DELIVERY. 555 

Let me put you on your guard, however, against too much 
confidence in the conservative power of this treatment. You are 
not to suppose that, because you may have dexterously relieved 
the patient in compelling the uterus to contract, she is, therefore, 
absolutely safe. It is true, you have arrested the flooding, for 
the present ; and it may not begin again : it is, however, still 
truer, that in most of the cases, the muscular irritability of the 
womb is below par, and that the effusion of the lochial blood, 
going on, however moderately, tends to fill up and again distend 
its cavity — which, the larger it grows, the more rapidly it bleeds, 
and so reproduces the feeling of faintness, with diminution or loss 
of pulse, anxiety, jactitation, and all the signs that attend ex- 
cessive sanguine effusion. Your most vigilant care is required 
to meet these symptoms in their very inception. You will dis- 
cover them early, if you be really panoptical in your vigilance — 
and you will put an end to the second and to the third attacks as 
easily as you did to the first ; and by the same method. 

A strong compress, laid on the hypogaster, and confined there 
by a binder, consisting of a long towel or pillow-case, will aid you 
to keep the womb from expanding again and again. 

As to a compress and binder — let me tell you, that I have 
many times been teased by them, when the tendency to repeti- 
tions of the hemorrhagic attacks was very strong — for the abdo- 
men being concealed beneath compresses and bandages, I found 
that I could not so perfectly observe the state of the uterus, which 
would steal a march on me by filling itself with a quantity large 
enough to make my patient ill before I could discover it. Much 
vexatious experience of this sort has taught me, long ago, that the 
best compress is my own hand, for it has the advantage of being 
not merely a compress, but an intelligent or perceptive one, one 
that is capable of telling me — "Sir, the womb is filling again. 
Take care it don't hurt her." 

As soon, then, as you can feel satisfied that the disposition to be 
hemorrhagic is over, you should adjust the compress over the 
uterine globe, and secure it with a bandage round the body. I 
advise you to do this with your own hand, in all serious cases of 
the sort, because you can better trust yourself than any nurse 
whatever. At least, your mind will be at ease, as you will know 
what you have done ; but you cannot know what another has done 
under your direction. 



556 FLOODING AFTER DELIVERY. 

There is another point that is worthy of your most especial 
regard in such cases. I mean the position of the patient. 

She must not sit up — she must not be inclined upwards, if she 
be really ill — she must have her head in the same plane as her 
hips — or, if she be very ill, you must, you must make her head 
lower than the hips, by putting some books, blocks, or bricks 
under the foot-posts of the bed, which will elevate the legs and 
hips, and depress the trunk and head. I have already said that 
fainting results from diminution of the tension of the vessels of 
the encephalon. Suppose a person to stand up and be bled at 
both arms — he would faint for twelve or sixteen ounces — but 
suppose him to be bled while lying down, he would bear the loss 
of twenty ounces, and if he were to be held with his head down- 
wards, you might take four times as much, probably, without caus- 
ing deliquium — when the head is down, the blood does not quit the 
brain so readily; but, as long as the encephalic tension is kept up 
by means of a due fullness of the vessels, there cannot be such a 
thing as a fainting fit. 

The precept then is, in all cases of faintness from flooding, to 
get the head down as low as may be. Therefore, take away the 
pillows and bolsters — and refuse to restore them until all danger 
is clearly over. This precept is so clear, so plain, and the rea- 
sons for it so understandable, that I have often times, when called 
in consultations, been amazed to find a medical brother, in good 
practice, and of considerable experience, neglecting it. I have seen 
such an one alarmed as to the state of his patient, and using 
all means to arrest the fainting, save the first and best — namely, 
the getting of the patient's head down. It was but the other day 
that I was called, in consultation, to a case of desperate flooding 
from placenta prasvia. I found the woman's head well raised on 
pillows. These pillows I not only took away, but I elevated the 
lower end of the bed, and bringing the head over the edge of the 
bed, allowed it to hang or droop down over the side with a view 
to keep the vessels of the encephalon full, for I know that as long 
as the encephalon is kept duly distended by vessels full of blood, 
so long will the brain generate and radiate its nerve force, its 
biotic force to the organisms — but if the brain cannot produce and 
send forth the nerve force, wherewith shall we carry on life in the 
organs? the heart will not beat, nor the diaphragm move, nor the 
par vagum do their office — and she will then die. 



FLOODING AFTER DELIVERY. 557 

Here is another point. It should be a rule to ask for informa- 
tion as to the habits of a patient, who may be placed under 
your care, in labor. Has she always had fainting, and floodings, 
when confined? If she has always suffered in this way, there is 
reason to think she will do so again, if something be not done to 
prevent it. 

Whenever I am informed, as to a patient about to enter upon 
her lying-in, that she faints and floods in labor, I invariably 
make arrangements to be provided with half a drachm of ergot. 
Let it be procured, and kept with the brandy, the laudanum, and 
the other preparations usually made for the exigencies of a labor. 

If a woman, who is within some ten or fifteen minutes of the 
conclusion of her labor, should swallow ten or fifteen grains of 
ergot mixed in water, the ergotism could not be developed until 
after the child's deliverance ; but, within ten or twenty minutes 
subsequent thereto, it would begin to excite the nerves of the 
womb, and compel them to compel the uterine muscles to con- 
tract, and to remain contracted. 

The power of ergot over the uterine nerves, and through them, 
over the muscles of the organ, is so great, that I confidently expect 
a woman, who has always flooded before, will not now suffer at all 
in that way if she take ergot. I say, I confidently expect it, but, I 
must admit, that an occasional disappointment is to be met with ; 
occasional I say, but those occasions are so rare, that I repeat, I 
confidently expect to obviate them. As an ounce of prevention 
is worth more than a pound of cure, I hope, when you come to 
practise, you will prevent hemorrhages in this way. Yet, if a flood- 
ing has not been expected, and comes suddenly upon your patient, 
you will have good reason to expect a tonic contraction of the 
womb to follow a good dose, — say fifteen to thirty grains — of 
the secale; give it, therefore, for there is no danger nor inconve- 
nience, since it cannot hurt the child, who is already born, nor 
will it do any evil to the mother. 

Do not be afraid of opium. Opium has a vast power over the 
hemorrhages, for it has a vast control over the innervative forces, 
and quells a hemorrhagic nisus as it quells a spasm of the sto- 
mach, or a toothache. 

I shall not dwell on the therapia of floodings any further. I 
have but one principle of guiding importance on the subject, and 
that is, to ensure by all the means in my power, the condensation 



558 AFTER-PAINS. 

or contraction of the uterine texture; all other views and treat- 
ment are to be held subordinate to these views, and the treatment 
that, under them, tends to bring about and secure this desirable 
end. If you understand this, and understand it fully, you cannot 
20 wrong; vou never will act wrongly in your methodus medendi 
for such cases. 

A woman who is confined for the first time, is not to be ex- 
pected to suffer from after-pains. A first gestation is, in general, 
insufficient to deprive the uterus of its tone; but if a woman have 
gone through a gestation and a labor a second, a third, or a fourth 
time, the tonicity of the organ will be found to be less than it 
was after her first confinement; and although the nervous force 
may be sent to it energetically, yet it will not be sent into it in 
the steady, equable manner which characterizes the condensing 
power of the uterus that has not already been exhausted by 
antecedent pregnancies, and the throes of parturition. 

There are some females, however, who preserve throughout 
life, and after repeated gestations, the same steady force as to the 
uterus, which characterizes that of the primipara. I have at 
this moment, under my care, a woman confined, now five days 
since, with her sixth child, and who has not had since the birth 
of it, and who never has had after the birth of any of her children, 
a single after-pain. This woman always recovers progressively and 
steadily from the gravid condition, without hemorrhage, without 
protracted lochial discharge, or any unusual symptom. Her 
uterus, which at the commencement of her labor, is ten or 
eleven inches in length, by eight or nine in width, and which 
would probably weigh, immediately after the deliver}* of the after- 
birth, a pound and a-half, goes steadily on, reducing itself to its 
non-gravid condition, wherein it would not weigh over two ounces 
and a-half. She has this good fortune, in consequence of retain- 
ing the same uterine tonicity, the same taxic force, that she had 
in her early youth, — and one meets in practice with a sufficient 
number of examples of the sort to convince him that the case 
is not a very rare one. 

You will find in your intercourse with the world, as a practi- 
tioner of midwifery, that the women, in general, are acquainted 
with this difference between the primipara and the muciparous 
female ; for they will say to you, — of the woman in labor, that, 
of course, she is not to have after-pains, because this is her first 



AFTER-PAINS. 559 

confinement, — or of another, of course, she is to have after-pains, 
because this is her second, her fifth, or her tenth labor. 

What is an after-pain? The pain of a labor is the pain felt at 
the cervix uteri, and is the result of violence done to the texture 
of the cervix and os, by the overpowering contractile force of the 
fundus and body. The pain is at the resisting part ; it is not 
suffered by the compelling organs. If a man strikes you a blow 
with his fist, and knocks you down, he hurts you and not him- 
self; in the same way, the fundus and corpus uteri, when they 
strive to rive open, and overcome the resistance of the cervix and 
os uteri, hurt them, excite pain in them, and sometimes even 
tear them to pieces. There are hundreds of women, in whom the 
circle of the os uteri is torn in labor; which is the reason why, in 
the examination of women who have borne children, you may find 
fissures in the anterior or posterior lip, or at the right or left 
angles of the lip, where the os is most likely to give way. 

I ask you again : what is an after-pain ? An after-pain is not 
designed to expel, unless there be a clot to be expelled ; and when 
there is in the womb a hard clot that will not break to pieces, and 
when the os uteri, immediately after the expulsion of the after- 
birth, has shut itself up like a steel trap, as it often does, the clot 
which cannot get out until the os uteri is again dilated, will ex- 
cite pain by dilating it, as the child did by dilating it. But there 
are thousands of examples where there is no clot to be expelled. 
When there is no clot to be expelled, the after-pains cannot de- 
pend upon the resistance of the cervix uteri to the contractions of 
the body and fundus. A woman who has an after-pain designed 
to expel nothing, will have the pain in the whole womb, not in 
the cervix, as in the labor pain. A pain in the whole womb in 
labor is a dangerous thing; it is a pain which proves the exist- 
ence of rheumatism in the uterus, or of a tendency to laceration of 
the organ. So that you see there is a difference between the true 
after-pain and the pain of labor. A woman in labor does not com- 
plain of pain and soreness if you press your hand upon the globe of 
the uterus, whereas, when she has just been delivered, she shrinks 
from the pressure, saying, " Sir, you hurt me — that is very painful." 
The whole womb is more sensible of pain, intolerant of pressure ; 
the function of its sensitive cords is exalted after labor. Now, 
during the moments of relaxation, while the sensitive fibres are not 
compressed in the tissues among which they are distributed, the 



560 AFTER-PAINS. 

woman feels no pain ; but as soon as the motor cords begin again 
to excite the muscular tissues, the passive tissues, among which 
the sensitive cords are also distributed, feel that pressure, and the 
woman feels the pain arising therefrom ; just as she feels the pain 
arising from the rude contact of your hand. 

In a former letter, I spoke of the frequent occurrence of rheu- 
matism as seated in the uterus; and I have no doubt, that many 
of the violent after-pains which we meet with, are cases of suffer- 
ing aggravated by a rheumatic condition of the organ; for, a 
woman who has suffered from rhematismus uteri for weeks before 
the birth of her child, I have always found more prone than 
another to suffer from these after-pains. — I mean with regard to 
their intensity, and their rebelliousness against the usual modes of 
treatment. 

An ordinary after-pain will be relieved by an opium pill weigh- 
ing one or two grains, or by two or three such pills ; or, it disap- 
pears after a few doses of laudanum, consisting of twenty-five or 
thirty drops each: a dose less than thirty drops it is hardly worth 
while to give. A woman may take an opium pill of a grain, or 
thirty drops of laudanum, every hour, until she has taken two or 
three such doses ; and it is rare to hear her complain of after-pains 
after taking the second, or more especially the third such dose. 
Camphor, also, has a very special power to take away the distress 
occasioned by after-pains : our good Dr. Physick was accustomed 
to say, that camphor seemed to have been made for women, Avith 
whom it always agrees, while it always disagrees with men. As 
a general rule, opium is preferable as a medicine to camphor, for 
it is less heating and less stimulating to the whole ecomony; but, 
inasmuch as there are idiosyncrasies which, under the use of 
opium, render it distressing or intolerable for certain persons, you 
should prefer for such persons the camphor medication. Here is 
a good formula. 



*.- 


-Camphor 


3ss; 




Pulv. gum. acacias 


3ij; 




Sacch. alb. 


3y; 




Aq. cinnam. 


fiij. 


M. 


ft. Mist. 






S.— The dose is 


a tablespoonful 



This will give you six doses, each containing five grains of the 



AFTER-PAINS. 561 

drug. You may give the second dose in half an hour after the 
first ; or in an hour or an hour and a half; the other doses may be 
repeated at longer intervals, pro re nata. 

Don't follow the old fashion, which commanded us always to 
send an eight ounce mixture to the patient ; a fashion, good for 
the apothecary, but very bad for the patient; for the nurse might 
make her sick by giving her a whole drachm, whereas she could 
not do her any mortal injury by giving her half a drachm of 
camphor. Drugs and medicines are a sort of edged tools ; and 
nurses and unlearned people, generally, are not to be permitted to 
use them, a la discretion^ as a French tavern-keeper says of the 
wine on his table. 

After-pains irritate; violent after-pains, frequently repeated, 
may irritate the whole constitution, even so far as to develop strong 
febrile phenomena. Where they are accompanied with fever, or 
frequent pulse, how can you discriminate between the phenomena 
so arising, and those attendant upon the most mortal attacks of 
metritis or puerperal peritonitis ? 

I pity you, gentlemen, from the bottom of my heart, for the 
distress and embarrassment you are destined inevitably to en- 
counter from the difficulty, nay, the almost impossibility of mak- 
ing a correct diagnosis in such cases. I think one of the most 
distressing nights of my professional life was passed in the 
apartment of a lady of the greatest worth, and of the highest 
social standing, who, after a long attack of rheum atismus uteri 
preceding her accouchement, gave birth to a feeble child which 
died a few days after it was born. The expulsion of the pla- 
centa was followed by severe after-pains, that deprived her of sleep 
during the night, and which, continuing in an aggravated form, 
during the following day, brought on a reaction of her heart and 
arteries, the pulse beating from one hundred and twenty to one 
hundred and thirty strokes per minute, and this, accompanied 
with the most intense pain of the abdomen as well as of the head. 
She was a person of great dignity of character, and the utmost 
propriety of conduct ; hence, the loud complaints she made con- 
vinced me, from my knowledge of her character, that her suffer- 
ing was nearly intolerable. I knew that she had had rheumatism 
of the womb before the birth of the child, and that the rheumatic 
condition had modified the muscular power of the uterus ; inter- 
fering with, and retarding the normal progress of the labor. But, 
36 



562 UTERINE NEURALGIA. 

when I discovered, six and thirty hours after the accouchement, 
that she had a pulse of one hundred and twenty, with a hot skin, 
and the most acute pain of the abdomen, I could not but hold her 
life to be seriously threatened. I passed the whole night, as I 
have said, in her apartment, agitated by the most conflicting opin- 
ions. Certain motives induced me to refrain from letting blood in 
the case ; and yet, when her groans and cries prompted me to 
come to her bedside, to examine with the most minute care the 
state of the pulse, of the respiration, of the calorific power, of 
the tension and sensibility of the abdomen, as well as the sensi- 
bility of the vaginal cervix as ascertained by the Touch, I always 
returned to my seat, comforted with the conviction, that I was 
treating a rheumatic neuralgia of the uterus and the splanchnic 
branches. The diagnosis was, in my opinion, undeniable ; yet, 
in half an hour, her cries and groans recalled me to her bedside 
to renew my diagnosis of rheumatism, and to go again and again 
through the same sea of trouble, of doubt, and misgiving as to the 
correctness of my judgment. For I said : If I judge wrong as to 
the diagnosis of the case, and if I lose this patient, I shall never 
again feel perfectly contented in this world. Happily for me, the 
morning brought a remission to the intense distress. My patient 
recovered from her Lying-in, and has continued ever since, now 
these many years, to suffer from distressing rheumatic neuralgia, 
in many parts of her person. 

I should in vain endeavor to put down upon paper the discrimi- 
nating signs by which you are to ascertain that your patient is 
laboring under rheumatismus uteri, or neuralgia of the womb, 
and not under some acute inflammation of that viscus. It is idle 
to write such a relation; a picture cannot be written ; it must 
be painted — nature must paint it for you — and you will find the 
picture in the clinique of your practice. Perhaps, if you and 
I were standing by the bedside of a patient laboring under this 
disorder, I might be able to point out certain signs, — discoverable 
in the physiognomical expression, in the tone of the voice, in the 
frequency, quickness and volume of the pulse, in the respira- 
tory acts, in the ability to move the limbs; in the patient's 
tolerance or intolerance of palpation, whether abdominal or va- 
ginal ; in the discharge from the uterus, and in the state of the 
urinary bladder and the bowels — that should show you why the 



UTERINE NEURALGIA. LOCHIA. 563 

case should be called neuralgia, and not metritis, or metro-perito- 
nitis. 

If you have studied your profession well, so that you have 
made yourselves masters of guiding principles in diagnosis, you 
will be able to find your way through these devious paths, and 
I must leave you to your own resources in the matter. 

I will not dismiss the subject, however, without first saying, 
that there is not a more difficult task to be performed by the phy- 
sician than to make the diagnosis in such cases. An antecedent 
rheumatic state of the womb may serve to lighten up the path of 
the observer, but, let him beware, oh! let him beware! that even 
rheumatismus uteri may pass into metritis or metro-peritonitis ; in 
which case, an error in judgment costs a human life ; costs the dis- 
ruption of the bonds of the family compact, the overthrow of the 
family altar, and the suppression of the most grateful incense 
that can rise to Heaven — the smoke of the incense that ascends 
to declare the happiness of parents and of children. 

The vessels in the interior of the uterus, that open upon the 
late placental superficies, continue to bleed after the delivery has 
taken place. In a womb recently emptied, there is a considerable 
number of patent orifices, of which you may see a very pretty 
drawing in Dr. Robert Lee's Treatise on some of the Diseases of 
Females, which represents the orifices arranged in such a fashion 
as to furnish them with a species of valve. 

The blood discharged from these vessels is called the lochia ; 
to. Tio^ca: %o%sla is the Greek word from which it is taken. It is 
called in German, Kindbettreinigung, and is called lochies in 
French. The discharge continues for several days. Between the 
third and fourth days, the abundance is less ; probably, because the 
forces are employed in determining the new movements towards 
the mammary glands, which now become centres of fluxion, 
whereby the granules of the gland are evolved, in order to the 
secretion of the nutriment of the new-born child. When the milk 
has been fairly secreted, the lochial discharge increases again; 
and on the sixth,' seventh, eighth and ninth days, it becomes more 
abundant than on the fourth and fifth ; so that, when your patients 
complain to you on the third and fourth days, of the diminution 
and almost disparition of the lochia] discharge, you should not be 
disconcerted, nor allow them to become so; seeing that it is not a 
morbid but a natural phenomenon. 



564 THE LOCHIA. 

In from six to ten days from the birth of the child, the red 
colored lochia has given place to a greenish or yellowish-green 
fluid, possessing a peculiar and often most offensive odor, power- 
ful enough to fill the w T hole of a large apartment; and so intense, 
that no scrupulous cares on the part of the monthly nurse can 
keep the patient's person and bed-clothes free from the disagree- 
able exhalation. The odor sometimes approaches that of sub- 
stances in a state of putrefaction and maceration, and the inex- 
perienced practitioner can scarcely avoid a feeling of doubt and 
distress as to the safety of the patient, considering the intenseness 
of the stench. But I believe that I can truly say, the woman 
whose lochia is so disagreeable as above expressed, is scarcely 
more liable to attacks of disease than she from whom no offensive 
exhalation can be perceived. I say this, founding myself upon 
much observation, for I have often experienced this great distrust 
on such occasions, when, it seems, I had no reason to do so ; nor 
can I remember that the attacks of disease that I have met within 
my lying-in patients, have been characterized by an antecedent 
unusual lochial odor. 

There are some women in whom the discharge continues until 
the end of the month; and it is by no means rare to meet with 
persons in whom it does not cease until the end of the sixth 
week. The greenish discharge, with its peculiar odor, gradually 
gives place to a colorless and bland mucus, which, for such 
women as have great powers of recovery, is gone entirely by the 
twenty-first day. I have seen a case in which the womb has 
apparently recovered its non-gravid magnitude in three w T eeks 
from the birth of the child; and I have seen a case in which the 
uterus, filled w T ith coagulated blood, extended nearly up to the 
umbilicus of the woman on the eighteenth day after the child was 
born. A womb that remains very large is more likely to give rise 
to a protracted lochial excretion than one that firmly condenses 
itself, and approaches the state of the non-gravid uterus. You 
will have, then, a prognosis that is favorable or unfavorable, ac- 
cording as the womb is large or small; — if the womb grows small 
rapidly, and puts an early end to the excretion, in consequence of 
its healthful condensing power, the woman is not likely to suffer 
danger from the cessation of the discharge; but if a womb remain 
large, and heavy, and doughy, and the discharge cease too early, 
or too suddenly, the diagnostic will be that of a pathological con- 



THE LOCHIA. 565 

dition of the organ, and the prognosis will flow out of that ; for 
an inflammatory condition of the organ could not but modify its 
power of excretion. In one case you may be called on to inter- 
fere therapeutically ; in the other, you do mischief by your inter- 
vention. 

When complaints are made to you on occasions like these, 
you should give them careful attention, and institute such in- 
quiries as to the state of the lochial organ, as must suffice to dis- 
cover the truth as to whether it be morbidly deprived of its 
excretive power, or whether it be physiologically deprived thereof. 

You will find, in the world, a foolish prejudice, especially among 
the less informed classes of the population, w T hich induces them 
to allow the accumulated products of the foul excretions of the 
uterus to rest and putrefy upon the external genitals, from an 
ignorant fear they have of checking a discharge so essential 
to their safety. I hope you will always endeavor to dissipate 
all false notions in relation to this matter; and you will not find it 
difficult to do so, if you will take the trouble to explain to the 
patient or to the nurse, that the putrid exhalations arising from 
the accumulated blood and mucus, at the orifice of the vagina, or 
within its canal, expose the woman to the dangers of putrid 
infection; and you should direct the nurse, in all cases under 
your care, to keep the woman scrupulously clean, by ablutions of 
warm water and soap, to which should be added some spirits or 
wine. For persons w T hose circumstances will warrant such ex- 
pense, I generally direct my nurses to make ablutions with red 
wine and water. I find that some of the brethren, and even some 
of the monthly nurses, in this quarter, are in the habit of ordering 
the vaginal injection; the circumstances would be very peculiar 
which should induce me to make such a prescription; for I con- 
ceive that, if the napkins that receive the discharge are changed 
several times a day; and if a sponge, squeezed oat in warm 
soap and water, or wine and water, be used as a detergent, the 
contractility of the tissues within will always emulge them suffi- 
ciently. I am not quite satisfied that it is the dictate of prudence 
or caution to fill the patient's womb with soap and water, or any 
other material of injection. 

In cold weather, and in the variable seasons, the spring and 
autumn, the woman should be carefully protected against the 
danger of taking cold, by undue exposure of these parts ; and 



566 THE LOCHIA. 

let me advise you to caution the patient against going, even after 
the lapse of the month, to the privy, the exhalations and the damp 
and cold of which render her very liable to repercussion of the 
fluxional movements, which should be most sedulously avoided. 

Some women have their lochia too profusely from getting up 
too soon: when they are too profuse, one of the most reasonable 
remedies will be found in ordering them to take again a recumbent 
or horizontal posture. Such a position, taking off the strain from 
the distal branches of the vessels, is alone, in many cases, suffi- 
cient to put an end to the morbid movement of the blood in its 
uterine and spermatic branches. When recumbency fails to cure, 
the question might present itself of the propriety of bleeding from 
a vein, in order to take off a portion of the injecting power of the 
systemic ventricle ; or, if such a procedure is not to be thought of, 
and if the excess be justly attributable to an ataxic or atonic con- 
dition of the uterus, one should direct the patient to take some 
astringent infusion; such as of red roses acidulated with aromatic 
sulphuric acid; or infusion of cinchona and cascarilla; or quassia, 
or chamomile, or infusion of krameria, diluted tincture of catechu 
or kino ; or some doses of opium ; or the saccharum saturni ; or 
alum and nutmeg powders, so often mentioned in these pages; or 
more than all, the vinum secale cornuti, or the secale in powder 
mixed with water. 

I shall take advantage of the present occasion, to refer you to 
the 220th page of that charming volume, entitled, " Lectures on 
the Theory and Practice of Midwifery, delivered in the Theatre 
of St. George's Hospital, by Robert Lee, F. R. S., &c. &c: 
London, 1844, 8vo.," a book which I could desire to be in the 
hands of every one of my pupils, as I look upon its author as the 
ablest man in all England, in this department of science and 
practice. 

I told him, in 1844, that he might safely die now. " Why 
die?" said he. — "Because you are already ineffaceably in- 
scribed on the roll of Fame." "How's that? how's that?" 
said he. — "It is thus, my dear doctor: — first, you are the man 
who has made the profession know the true nature of phleg- 
masia-alba-dolens ; it is you who have taught us the malady is 
crural phlebitis : — secondly, you are indissolubly united with that 
company of men who have established the spontaneous ovula- 
tion as a cause of menstruation. Nothing can separate your 



THE LOCHIA. 



567 



fame from that of Negrier, Gendrin, Pouch et, Purkinje, Von 
Baer, Rudolph Wagner, &c. Thirdly, you have just now shown 
me your last and greatest discovery, that of the largest ganglion 
in the human body, to wit, the cervical ganglion of the womb. 
I don't see anything left for you to discover, and therefore, I say, 
you may die now ; nothing can prevent you from being immortal." 
Dr. Lee replied, " I'll no die yet ! I'll no die yet!" — and I am very 
glad to learn that he is still living and in excellent health. Such 
people ought to die of old age, and nothing else, as we say in 
America. 

But, to return to his 220th page ; he says: — "This discharge 
from the uterus after delivery, called the lochial discharge, does 
not usually cease, altogether, until the uterus has contracted 
greatly, and become much reduced in volume by the absorption 
of its coats, blood-vessels and nerves. The uterus is much more 
rapidly absorbed in some women than in others, and this chiefly 
depends on the previous state of the patient's health, and the 
nature of the labor." 

I cannot agree with Dr. Lee in the opinion that the uterus is 
absorbed; because, I look upon the virgin uterus as a gravid 
uterus inpotentia; a uterus possessing every organ and part of 
an organ that is necessary to enter into the composition of the 
gravid womb; which, when it returns to its non-gravid condi- 
tion, does so, doubtless, by the aid of much absorption, but not 
by the "absorption of its coats, blood-vessels and nerves ;" for I 
conceive them never to be absorbed. Dr. Lee might as well say 
that the granules of the female breast are absorbed after the 
weaning of the child, or that they do not exist in the virgin ; but 
he knows that Sir Astley Cooper has demonstrated them to exist 
even in the male gland. I offer this little criticism on the 220th 
page of my excellent friend's work, because, although " aliquando 
bonus dormitat Homerus" Homer himself ought to be waked up 
when he nods. 

It is customary to put a binder around the abdomen of a woman 
just confined; a precaution rarely neglected in this country; but 
which, being neglected, is assigned as the cause of much after- 
suffering and ill-health that the patient causelessly attributes to 
the ignorance and carelessness of her monthly nurse, or her medi- 
cal attendant. 

It is necessary that you should be cautious in the use of the band- 



568 THE BINDER. ASDRUBALI. 

age; for, if the bandage be worn too strictly, and with a heavy 
compress between it and the abdomen, it cannot but happen that 
the globe of the womb, which for a few days after delivery, is as 
large as a cricket ball, will be thrust down into the excavation, 
pushing the vagina before it, thus shortening the tube, on the 
upper extremity of which the uterus rests, and which, in fact, fur- 
nishes to the uterus nearly its sole support, amidst the bones of 
the pelvis. Suppose you were to fix one of the utero-abdominal 
supporters, as they are called, upon the hypogastrium of a woman 
just confined, and compel her to wear it for the forty days ensu- 
ing, or until the uterus had recovered its non- gravid magnitude 
and weight, would not your patient be sure to recover with a pro- 
lapsus uteri? 

You will find, at page 208 of Prof. Asdrubali's work, " Tratato 
Generate di Ostetricia, Teoretica e Pratica" vol. 2d, some excel- 
lent observations on the evils and abuse of bandages; and inas- 
much as, throughout the United States, the most incorrect and 
harmful notions exist on the subject, I think I shall do you no 
disservice if I translate the whole passage from that most learned 
and admirable author. 

" The habit of binding up the abdomen of women in child- 
bed, was in use among all the ancients. Yet Peu and Mauriceau 
have declaimed against the abuse of it, though they did not admit 
that it should be wholly proscribed. Many of the moderns still 
advocate its employment, but with great precaution ; as if in doubt 
whether it might do most good, or most harm; but the majority 
of them have condemned the custom. Buchan looks upon it as 
absurd, and Gorter as mischievous, and as the occasion, almost 
always, of serious disorders. 

" Among the motives that have prevailed among some, to re- 
commend the binder, the principal one was to furnish the patient 
with the same sort of aid as it is customary to give the patient 
in dropsy, after the operation for paracentesis, with a view to 
prevent attacks of lipothymia and syncope, likely to ensue upon 
the sudden and great evacuation of the abdominal cavity. An- 
other motive was, to restore to the abdomen its non-gravid size 
and form. » 

" It is not to be doubted that the cavity of the abdomen, when 
compressed by the binder, will find as much support for the com- 
pression of the viscera and blood-vessels, as it had previously 



THE BINDER. ASDRUBALI, 569 

received from the gravid uterus. But, inasmuch as, for the 
obtaining of this effect, the abdomen must be firmly bound, 
and as there is no other motive for it, the constriction, no doubt, 
is often sufficient to produce suppression of the lochia, whence 
may arise suffocation and pain, which are the beginnings of 
terrible maladies. How some recommend it without clear mo- 
tives, and others advise it under careful restrictions, is demon- 
strated by daily observation ; for it is observed that no evils befall 
those w T ho make no use of the binder, but leave the abdomen per- 
fectly free: they pass through the puerperal state without the least 
untoward circumstance. Why should we resort to a method 
from which, as Dionis observes, there proceeds more mischief 
than good? In order to avoid deliquium and syncope, it is only 
necessary that the woman, as soon as she is confined, should pre- 
serve a horizontal posture ; and if, unexpectedly, or by accident, 
deliquium should occur, certainly w T e might make use of remedies 
equal to the removal of the evil, and prompt in their action, and 
not trust to a mere bandage. If a woman should have an extra- 
ordinarily flaccid abdomen, it might certainly be advisable to con- 
tract it by a bandage made moderately tight, and kept so, for a 
few days. 

" The second motive for recommending a bandage is, as ex- 
pressed in § 282, to reduce the. size of the abdomen of the puer- 
peral woman. But experience shows that the restoration of its 
shape depends upon nature, and not upon any art whatever. The 
abdomen, as soon as it is relieved from its distension by the gravid 
uterus, recovers such form and size as it is susceptible of, under 
the contraction of its muscles and teguments : it would not, cer- 
tainly, be susceptible of a corrugation beyond the natural degree, 
by any restraint afforded by a linen bandage. How true this is, 
may be observed in many women, who, after repeated labors, find 
the abdomen relaxed and flaccid, notwithstanding their extrava- 
gant sacrifices to the dictates of fashion in dress. They look to 
the physician for this happy restoration ; they suppose that he, by 
means of his bandage, ought to restore the abdomen to its primi- 
tive condition; never reflecting, that they wear corsets without the 
least advantage, and that the support they require for too flac- 
cid an abdomen, is to be obtained from the ordinary corsets and 
busks, which they can tighten at will, and to which they can 
give any form, adapted to their necessities or caprices.' 5 Professor 



570 RETENTION OF URINE. 

Asdrubali concludes his article with a considerable quotation 
from Lemoine, which I shall not cite to you for the present. 

I have already, in a former letter, offered you some remarks upon 
the use of the bandage, as a means of suppressing the tendency 
of the uterus to expand soon after labor, and receive, and contain 
the products of what is called a concealed hemorrhage, for which 
I refer you to page 549. I likewise expressed the opinion, that 
certain women, after sudden deliveries, having had the womb 
enormously distended before, suffer from violent lipothymia and 
deliquium, for want of some abdominal tension, for want of a 
bandage. For such views, I hold the bandage to be laudable, 
and the use of it not to be pretermitted ; but as for the rest, I 
here fully give my approbation to the sensible, reasonable remarks 
of Professor Asdrubali. It is very probable that much of the pre- 
valence of prolapsus uteri in this country is due to the improper 
use of the binder. Pray attend to this point. 

There is one point in the management of women newly de- 
livered, to which I must now advert. It is a very common occur- 
rence to find the woman recently put to bed, affected with reten- 
tion of urine; the occurrence is so common, that it is a rule of 
duty in the physician who has charge of the case, to make in- 
quiry into the matter. It cannot but be inconvenient, and not a 
little dangerous, to allow the products of the renal secretion to 
accumulate in the bladder to a great amount. But, that organ 
has been so much distressed, so much compressed, and, perhaps, 
so much contused in the transit of the foetus through the pelvis, 
that it must be, and, in fact, it is an exceedingly trite occurrence 
to find the woman allowing from thirty to forty ounces of fluid to 
accumulate in the bladder of urine, putting the cystic tissue 
dangerously on the stretch, compressing the uterus, exciting pain, 
urinary and rectal tenesmus, and even fever, which it is easy to 
guard against by a simple precaution. It is considered by 
accoucheurs, therefore, an invariable point of duty, to inquire, 
within a few hours after the birth of the child, whether the bladder 
of urine has been relieved. 

If you, who read this letter, be not, and do not intend to be- 
come an accoucheur, you might nevertheless adopt the custom of 
the accoucheur in such cases. An accoucheur would not think, I 
suppose, of giving medicine to provoke a discharge of the urine 
in such a case. An accoucheur does not like his patient to be 



RETENTION OF URINE. 571 

disturbed by a dose of physic, or even by a common aperient 
enema, in the first two days at least of the lying-in. He knows 
that drugs are of no avail for this kind of retention, and he resorts 
at once to a remedy which cannot fail, which is not inconvenient, 
and in no wise painful : I mean the introduction of the catheter. 
If the woman should not be relieved in the course of from eight to 
twelve hours, the catheter should be introduced, and so on from 
day to day, until the power of the urinary organ be quite re-estab- 
lished. 

I pray you remember, that you might make a false diagnosis 
in the matter, if you be not careful. I have seen this false diag- 
nosis made a thousand times by nurses and by the patients them- 
selves ; they supposing the distress to arise from what is called 
after-pains, while, in fact, it depended solely upon retention of 
urine and extraordinary distension of the bladder of urine. If, for 
a woman complaining of after-pains, you should explore the case, 
by pressing your hand upon the hypogastrium, and finding there 
a well defined, resisting, orbicular mass, nothing would be easier 
than to mistake it for the uterus. Sometimes, I have had a 
difficulty in making the discrimination, by trusting merely to my 
sense of touch: the difficulty of diagnosis has vanished from 
me always, however, upon ascertaining : — first, that the woman 
has had no urinary evacuation for a number of hours; and 
secondly, by saying to her, " Listen to me; attend. I am press- 
ing my hand upon a lump which I find here at the lower part of 
the stomach. I am going to press harder, in order to give you 
some increase of pain. Please give your attention to the sort of 
pain which I shall produce ; — and tell me whether or not the pain 
you now feel may be truly called a urinary pain. Is it a pain to 
make water ?" 

"Yes, sir, it is !" 

"Very well. — I understand the case now." 

After such an answer, a doctor would be very stupid if he 
should not propose the use of the catheter. 

After severe labors, the bladder is occasionally found to refuse 
to resume its function of expelling the urine for three, eight, ten, 
and sometimes fifteen or twenty days. As long as it refuses to 
do its duty, the medical man should remove the urine twice a 
day, or, what is far better, leave a proper catheter in the hands of 
the patient; first instructing her to apply it for her own relief. 



572 RETENTION OF URINE. — MEDICINE. 

There are many persons who can be trusted to do this little ope- 
ration, which is a saving both to their own feelings and those of 
the medical attendant, for there is scarcely a more disagreeable 
operation to be performed than that of catheterism of the female ; 
an operation which, I should think, every gentleman would be 
glad to commit to other hands than his own. It does no mischief, 
I suppose, in such cases, to give a little sweet spirits of nitre ; to 
give a little weak solution of nitre; to allow your patient to take 
infusion of watermelon seed ; of parsley root, of horseradish, or of 
juniper berries; which do little harm, and less good. If the 
patient will have a placebo, let her have the most innoxious one 
you can devise. After all, there is nothing for retention of urine 
like a good catheter. 

It is not good practice to excite perturbations in the economy 
of a woman who has just gone through the pain and excite- 
ment of a labor. Such a person requires a long and profound 
repose of the organs and organisms, as well as of the spirit itself; 
for which all sorts of complacencies ought to be provided. A 
dose of cathartic medicine, administered within twenty-four hours, 
is sufficient, in some instances, to call up movements, whether 
nervous or vascular, that it would be far wiser to leave uncalled. 
Wake not the sleeping lion. Attacks of engorgement and inflam- 
mation have, I am sure, followed the intempestive exhibition of 
purgative medicines, by imprudent and assuming nurses. It is time 
enough, under all ordinary circumstances, to cause the bowels to 
be moved once or twice, after the lapse of from sixty to seventy- 
two hours; and the woman ought not to be disturbed with any 
kind of physic for at least this length of time after her delivery. 
When the time does arrive for giving some medicine, an aperient 
ought to be selected, and not a purgative. The patient is not sick ; 
she does not want physic ; her bowels are lazy, and merely re- 
quire to be roused a little ; the woman ought to have one or two 
alvine dejections, and not more, unless she be really sick. To 
procure this desirable end, pray select some article that you can 
depend upon. Can you depend upon magnesia, or upon the com- 
mon combination of magnesia and Epsom salt? No. A dose of 
magnesia will operate either not at all, or once, or eight or ten 
times. Will senna or rhubarb answer your purpose? Unfaith- 
fully ; because they bring on purging, if you give a sufficient dose ; 
and if you give a moderate dose, you will be disappointed in the 



MEDICINE. DIET. 573 

operation. What is the medicine that doesn't disappoint you? 
Castor oil. The dose of this medicine ought to be, as a medium, 
about half a tablespoonful. In ten cases of women just confined, 
a dessertspoonful of castor oil will be sufficient for nine of them, 
and the tenth one can repeat it after five or six hours, if she 
chooses. I aclvise you to follow this method; and I confidently ad- 
vise you in this way, because "haud inexpertus loquor." Neither 
my friend Dr. Samuel Jackson, nor I, would consent to give a 
woman a tablespoonful of castor oil under such circumstances, 
because we know that half a tablespoonful is a better dose for 
her. Dr. Jackson is a good authority in matters of therapeutics. 
I wish there were more like him in the country. 

The diet of the woman is worthy of some consideration: many 
women are left by labor with their blood-vessels in a state of con- 
vulsion, so to speak; the tempest and whirlwind of their passion 
do not subside, for many of them at least, for hours after the 
provoking cause has been taken away. 

If the woman has not lost a great quantity of blood by the de- 
tachment of the placenta ; or if the lochial discharge should prove 
to be not very abundant, the materials for development left within 
her blood-vessels ought not to be deemed to require much refec- 
tion for two or three days. She is about to have a new cause of 
constitutional disturbance set up within her: both the mammary 
glands are destined to sudden, I was going to say, bursting de- 
velopment. They are both about to become suddenly instinct 
with life ; an operation attended, in the majority of cases, if not 
with fever, at least with a quasi febrile paroxysm. 

These considerations render it expedient that her diet should 
consist of very light, digestible, and sufficiently nutritious mate- 
rials. I presume that in different parts of the country there are 
different modes of treating the lying-in woman as to her diet; but 
as for us in Philadelphia, a time-honored custom, which is uni- 
versally adhered to, commands the nurse to provide for her patient 
a diet of gruel made with oatmeal. Many of the nurses boil it 
into a thick porridge, and give it to the patient sweetened with 
sugar, after having made a very slender addition of salt; it is 
light, aperient, agreeable to the patient, and satisfies well the 
cravings of the stomach. 

The woman is also allowed a cup of tea, and some dry toast or 
baked rusks; or any simple preparation of bread. Tea and toast, 



574 DIET. SITTING UP. 

oatmeal gruel and cold water are a lying-in woman's allowance, 
until after the milk comes, in Philadelphia. Hot tiff, or brandy 
and water; soups, meats, eggs; all animal substances, ought to 
be proscribed. 

A woman ought to keep her bed for the first nine or ten days 
after her accouchement; if she gets up, the womb descends into 
the excavation, lower than the place it ought to occupy. The womb 
will get well, notwithstanding such imprudence ; but the vagina 
may be ruined, and the woman's health may be forever after dis- 
turbed by a prolapsion, which always coincides with a shorten- 
ing of the vagina. Prolapsus uteri means, and is nothing else 
than shortening of the vagina; and you have nothing to cure in 
prolapsus uteri but a shortening of the vagina ; and when it 
is cured, the woman is cured, and you have nothing else to do 
with it. 

There is another motive why a woman should not get up, aris- 
ing from her extraordinary nervous susceptibility after labor. She 
may take cold ; she may be seized with a rigor ; and the rigor may 
give her an attack of weed in the breast ; or the force of the re- 
action may fall upon the womb, or upon the peritoneum; so that 
she shall pay for her imprudent early rising with a mammary 
abscess, or by loss of her life in a child-bed fever. I verily be- 
lieve, that one half of the vexations I have experienced in the 
course of my life, from such occurrences, have been the fruit of 
untimely, imprudent exposure as to diet, or as to too early rising 
from the bed. I tell my young lady-patients that if they keep 
the bed until they are cured, child-bearing will not make them 
break, — as it is called. A squaw, with two pappooses, is nothing 
but a squaw. She might have been a very pretty woman still, if 
she had had a good nurse, and kept her bed until after the ninth 
day. She who gets up too soon will have wrinkles, and grow 
sallow and ugly before she is twenty-five. 

After the ninth day has elapsed, if nothing has happened, the 
woman may be taken up for an hour in the morning, and again 
as long in the afternoon ; prolonging from day to day her leave of 
absence from the couch, until her strength being gradually re- 
stored, there shall seem no longer need for any restriction what- 
ever. 

I shall refrain from offering remarks here on the coming of the 



RIDING OUT. VACCINATION. 575 

milk, and the management of the breast, as I intend to devote a 
separate letter to that consideration. 

As to riding out, it will depend upon the state of the patient's 
health; it is well, however, to have a rule; — my rule is to say, 
you may ride out on the twenty-first day, if you be w T ell enough 
and the w T eather be inviting. An hour's ride is long enough for 
the first sortie. But, if the lochia are not gone, it is better to stay 
at home. 

No woman ought to consider herself recovered from the effects 
of her accouchement, until after the lapse of an entire month. 
The Jews, who inhabited a very warm climate, were consi- 
dered, by their Lawgiver, unclean for forty days after the birth 
of the child. Christian women are purified in thirty days, and 
I am afraid that some of them think themselves so earlier than 
that. I wish that the brethren could lend their influence to 
reinstate the Mosaic doctrine on this point. But, some people 
will not believe Moses nor the prophets ; nor w 7 ould they believe, 
though one should rise from the dead to tell them, they are not 
well, if they but feel well. 

Pregnant women ought not to be vaccinated. — This is a rule 
that I advise you to depart from only on the most urgent occasions. 
If a woman have been once vaccinated, and appeal to you to re- 
vaccinate her because there is a present variolous epidemic, I 
hope you w r ill refuse to accede to her request. Small-pox is ex- 
ceedingly and peculiarly pernicious to pregnant women. — She 
who has it, and miscarries — or who is brought to bed at term, 
generally dies. It is, in my opinion, inexcusable to expose her 
to so great a risk — a risk far greater than that from accidental con- 
tagion, or that of the epidemy. But the vaccine is identical with 
the variolous animal poison, saving some lessened intensity of its 
malignant form derived from its having been modified by the nature 
of another mammal. — To inoculate a cow with small-pox virus, is 
to give her the vaccine disease, with the lymph of which you 
can vaccinate, but not reproduce unmodified small-pox. Keep 
your pregnant patients clear of small-pox in all its forms, whether 
modified or unmodified. — Do not vaccinate them. I have been 
the witness of dreadful distress from the operation. — Eschew it, I 
entreat you. C. D. M. 



576 



PUERPERAL FEVER. 



LETTER XLI. 

Gentlemen: — There is a "word of fear" that I shall pro- 
nounce when I utter the name of Puerperal fever; for there is 
almost no acute disease that is more terrible than this — even 
small-pox, which reduces the fairest form of humanity to a mass 
of breathing corruption, cannot be looked upon with greater awe, 
since, like an inexorable Atropos, it cuts off the thread of life for 
those to whom Cloth o and Lachesis would give the longest span. 
There is something so touching in the death of a woman who has 
recently given birth to her child ; something so mournful in the 
disappointment of cherished hopes ; something so pitiful in the 
deserted condition of the new-born helpless creature, forever de- 
prived of those tender cares and caresses so necessary for it — that 
the hardest heart is sensible to the catastrophe. It is a sort of 
desecration for an accouchce to die. 

The disease in question, from its liability to assume the cha- 
racter of a devastating epidemic, acquires an importance far 
greater than would appertain to it, were it limited to the occa- 
sional fatalities of its sporadic or accidental formulas — for when it 
does prevail as an epidemic, it sometimes rages over a great ex- 
tent of country, or districts, and lays not aside its destroying wrath, 
not for weeks only, or months, but even for a term of years ; 
carrying in its train fear, expectation of death, and the overthrow 
and desolation of the domestic altar. 

The maladies comprised under the denomination of puerperal 
fever, for there are several of them, are so insidious in their ap- 
proach, so sudden and violent in the attack, and so rapid in their 
progress, that the fatal boundaries are not unfrequently passed 
before assistance is sought for from the hands of the physician. 
It is, therefore, clearly your duty to make yourselves accurately 
acquainted with its nature, signs and treatment. I shall accord- 
ingly, in the present letter, endeavor to lay before you such 
views upon the subject as I have been able to obtain from no little 
clinical observation of cases, from reflection upon what I have 
myself seen, and from conversation and reading. 



PUERPERAL FEVER. 577 

Puerperal fever, denominated, by the public, child-bed-fever, 
is also called peritoneal fever, puerperal peritonitis, metritis, 
metro-peritonitis, uterine phlebitis, and lastly, pyogenic fever: it is 
a disease consisting of inflammation of the serous coat of the abdo- 
men, or of some portion of it — inflammation of the ovaries — one 
or both of them; of the womb, with, or without coincident inflam- 
mation of the peritoneum; of the veins of the womb; or of the 
absorbent vessels of that organ. 

It is probable, that a major part of the cases consist of serous 
inflammation only, — cases in which the sub-serous textures have 
little participation in the pathological modifications of the peri- 
toneum proper. 

Many of these samples of peritonitis, however, coincide with 
violent inflammation of one or both of the ovaria — of the liga- 
menta lata, and of the external superficial tissues of the uterus. 

In pure samples of metritis — or of uterine phlebitis, the inflam- 
matory modification of the tissues may not, on the one hand, or on 
the other may, extend to, and involve the serous lining of the 
womb, and spread far and wide throughout the various folds and 
reflections of the whole peritoneum. 

Leaving out of consideration the nature of the recondite causes 
that operate upon the economy to develop the various puerperal 
inflammations; such as an epidemic or an endemial influence; or 
a poison conveyed in the clothing or persons of physicians and 
nurses, one would seem to perceive sufficient provocatives to the 
attack of inflammation, in the state of the parturient woman's con- 
stitution, and in the events of the labor by which she may have 
been brought to bed. Indeed, there is room for surprise, that the 
examples of violent inflammation of the tissues concerned in par- 
turition, are not far more numerous than they are really found 
to be. 

In the first place, it is extremely rare to let blood for a patient 
pregnant and nigh to her term, without discovering the proofs of 
an inflammatory tendency, in the sizy and cupped appearance of 
the blood, when allowed to lie in a state of rest. I beg you to 
take notice, in your subsequent practice, of this point. — But if the 
blood be sizy in nearly all pregnant women, then all such women 
are, to say the least, in a state of proneness to inflammatory 
attacks — since that siziness of the blood indicates an excessive 
predominance of the fibrinous element. I beg you to allow me 
37 . 



578 PUERPERAL FEVER. 

to repeat, that in 1,000 grains of healthy blood, there should be 
found not more than 3*5 of fibrine — but, if you bleed a pregnant 
female far advanced in the gestation, you will discover size 
enough in the coagulum to lead to the supposition that instead of 
3*5 there must be not less than 10, or perhaps 15, of the plastic 
material. 

Pregnancy, for most women, is carried on at the expense of an 
.exalted general vital force, — for many of them, the latter weeks 
'of gestation are weeks of feverishness ; and when, upon such a 
basis of dyscrasy of the blood, we come to superadd all the san- 
guine and nervous exaltations of the conflict of labor, which is 
attended with greatly increased action of the heart and arteries, 
we may well believe that the blood is invariably left in a patholo- 
gical condition at the delivery. 

The nervous system, too, in most cases of hard labor, becomes 
exhausted, and is rendered thereby extremely impressionable by 
all morbific causes : all the causes of inflammation must act with 
redoubled intensity upon it, and inflammation once begun, may, 
with difficulty, be prevented from extending far and wide beyond 
its radiating point. 

As to the serous lining of the abdomen, there is scarcely any 
portion of it that is not affected, in pregnancy, by the vast exten- 
sion of the peritoneal superficies of the womb and the abdominal 
integuments, or by the pressure effected upon them. 

The birth of the child takes off this pressure — leaves much of 
the peritoneum in a state of relaxative flaccidity — and thus brings 
it into an ataxic condition, inviting the approach and onset of 
disease. 

The repeated, protracted, and vehement contractions of the 
abdominal muscles, cannot but have a tendency to effect contu- 
sions in the opposite surfaces that are so violently jammed or 
ground together during the labor throes ; while the lower portions 
of the membrane or the cervical portion of the uterus, contain- 
ing within it the foetal presentation, are thrust with an incalculable 
force down below the plane of the superior strait, and oftentimes 
held for hours against some part of the osseous structure of the 
pelvis ; so that one is amazed to find the tissues escaping wholly 
from disease, when it was probable they could not escape absolute 
destruction. 

Consider also the state of the textures composing the womb 



PUERPERAL FEVER. 579 

itself; and reflecting that the power of the womb is resident only 
in its muscular fibres : see what and how great must be the 
mechanical violence done to the remaining elementary structures 
of the organ during the protracted and agonizing contractions of 
those muscles, — contractions that seem, in some instances, to 
make every sensitive cord feel the violence that is directed and 
occasioned by the motor cords. 

The labor, too, is not the end of the scene, for the womb and 
the vagina, with their whole cortege of arteries, veins, capillaries, 
nerves, and absorbents, as well as the muscles and cellular tela, 
are passing, during forty days after the birth, back again into 
the non-gravid state ; a transition-period, full of hazard, and open 
to the attack of inflammation. 

There are new determinations of blood to be established. The 
torrents that have poured for months, and in increasing volumes, 
along the uterine and spermatic branches, are suddenly cut off in 
a measure by the closure or quasi obliteration of their accustomed 
channels ; and great veins and sinuses, as big as a little finger, 
must allow their walls to collapse, compelling their endangium to 
re-enter the state of non-gravid abeyance from which the preg- 
nancy had forced them to issue. 

Upon the interior surface of the uterus is left the cotyledynous 
superficies, with the patulous orifices of the lochial vessels, that 
were uncovered by the detachment of the placenta. Those mouths 
are often bathed with fluids of the most putrid and offensive and 
even acrid character, provoking inflammatory exaltation of the 
capillary and nervous textures, and the endangial tissue of the 
veins. 

Finally, the new life-force in the breasts must begin ; and the 
firm tension of the mammary glands and galactophorous tubes 
developes fever, which is akin to inflammation. 

In addition to all the causes above enumerated, it is proper 
to take into consideration the state of the skin. There are few 
women who go through with the labor without violent perspira- 
tion, which issues from the head and thorax, and flows in copious 
streams. Such a condition of the cutaneous exhalants leaves the 
delicate vascular and nervous apparatus of the skin in a highly 
susceptible or impressionable attitude, so that cold and damp ope- 
rate with peculiar intensity in causing disease. 

There are, besides, many labors that are interfered with by the 



580 PUERPERAL FEVER. 

officious intermeddling practitioner, whether male or female, who 
happens not to have been well instructed in the duties of the 
obstetrician. Instruments are the not unfrequent causes of con- 
tusion, as well as of laceration of greater or less moment; so 
that multitudinous provocatives and causes of disease are to be 
discovered, even in the most simple healthful case of parturition. 

There are, moreover, epidemic causes of puerperal fever. I 
cannot tell you what is an epidemic cause, since it is uncognos- 
cible, recondite, and beyond the ken of the human understanding. 
We can know that it exists, and we can witness the efficacy of 
its awful causation, in the frightful devastation of hospitals, towns, 
villages, and even large and extensive districts of country. 

Dr. Sydenham showed long ago, that a constitution of the 
atmosphere may exert modifying influences upon the nature of 
diseases, and, that as the constitution changes from time to time, 
so will the characteristic qualities of any disease undergo con- 
formable modifications from year to year. He showed that there 
may reign influences to render prevailing maladies either syno- 
chous, or typhous, so that the fiercest attack of pleuritis shall par- 
ticipate in the nature of the most ataxic forms of the typhus fever, 
or upon some unknown non-meteorological mutation of the quali- 
ties of the ambient air, the serous inflammations shall recover all 
their activity and red-hot intenseness. 

No eudiometrical researches have hitherto succeeded in wresting 
from Nature her direful secret as to the essence of epidemic causa- 
tion. The poisonous exhalations from the bogs of the Valteline, or 
the marshes of the Campagna, in the eudiometer betray no combi- 
nations of the air different from those that rest on the pinnacle of 
the Shreckhorn, or the Faulhorn ; no additional infusion of car- 
bonic acid, no supersaturation of oxygen, nor excessive nitro- 
genous dilution. Hypotheses and conjectures, however specious 
and plausible, are all that we have to rest upon in the arduous and 
anxious explanation. 

In the case of the confessedly contagious disorders, we seem to 
come at something like approximation to the truth. We can, in 
the case of small-pox, visibly and palpably demonstrate, if not 
the essence of the contagion, at least the contagious virus, a ma- 
terial in which it exists. We can take it from one, and transfer 
it a thousand leagues to another, and plant, as it were, its seeds 



PUERPERAL FEVER. 581 

to spring up like a vast Upas, overshadowing with its arms of 
death, the whole area of a city or a county. 

Perhaps there are other maladies, as scarlatina, rubeola, per- 
tussis, &c, that may be placed in the same category of contagious 
power. Yet, if we be compelled to admit that they are propa- 
gated by contagious force, we cannot deny that they are also 
extended among a population by epidemic causations. Willis, in 
his Tractatus de Febribus, says, Peculiaris quaedam aeris dispositio 
variolas insigniter producit; hinc ssepissime popularis evadit, ac 
per totas regiones, urbes, vicosque passim desasvit ; hinc etiam 
vere et autumno crebrior existit, &c. How are we to explain 
this epidemical power of a purely contagious malady, if we deny 
that there is a means of its evolution, utterly independent of all 
somatological sources of its production! 

In the great example, the Asiatic cholera, we have seen that the 
epidemic causation has risen into activity in various latitudes and 
longitudes of the globe, commencing in the Delta of the Ganges, 
and spreading eastward to China, and westward to Persia ; north- 
ward, to the shores of the Caspian, at Astracan, and to those of the 
Mediterranean, at Latakie ; ascending the Russian rivers to Mos- 
cow, and then invading Western and Southern Europe, and the 
countries of both North and South America. 

In the disastrous spread of this great epidemic, which has pro- 
bably cut short the span of more than fifty-five millions of our race, 
how many thousands of the strongest proofs have been observed 
of its contagious power, and yet it is probably not more contagious 
than rheumatism, or gout, or ordinary ague and fever. 

As to the contagiousness of small-pox, I cannot deny it, since 
I cannot deny the contagiousness of any innoculable malady. But 
the contagious nature of puerperal fever, though asserted by so 
many of the brethren, entitled to my respect for their learning, judg- 
ment, and humanity, I cannot for a moment admit. Its epidemic 
power is for me a sufficient explanation of all the asserted ex- 
amples of its communication by direct contagion. 

Sydenham, as I have said, made us acquainted more exactly 
with the important fact that changes in what he calls the consti- 
tution of the air, by which he means certain non-cognoscible 
cosmic forces, are capable of modifying the intenseness of our 
vital sensibility and irritability. Those same influences exerted 
in space, whether vast or minute, may serve to explain how ir 



582 PUERPERAL FEVER. 

happens, that in a district of country where a case of puerperal 
fever had been unknown in the memory of the oldest inhabitant, 
a major part of the puerperal women shall, for a series of months 
or years, become the subjects, and many the victims of it. An 
epidemic influence, be it what it may, can place the constitution 
in a predicament that renders it prone to be affected by the in- 
flammations that I have, in the beginning of this letter, deno- 
minated the textural lesions of our disease ; and to the end of 
conceiving of such epidemical influence, it is not necessary to 
imagine any fermentative or sporiferous element of propagation, 
nor any poisonous exhalation, material, or gas — since the small- 
est change in the atmospherical mixt, or constitution, can give 
the utmost vigor to the vital forces, or take them away, or reduce 
them to the minimum of power. 

The gigantic ferns that lie buried beneath the ruins of the ante- 
diluvian world, and the inexhaustible deposits of carbon in the coal 
fields and in some of the rocky strata, have been presented by the 
geologist as proofs of a former different combination or mixture of 
the atmosphere, as to its carbonaceous portion. But, if the geolo- 
gist has a real foundation for such an hypothesis, we shall not do 
violence to the spirit of philosophy, in supposing that atmospheric 
combinations and mixtures, excluding the idea of poisons, may 
reign in hospitals, cities, counties, districts, or states, for the pro- 
duction of epidemic maladies. 

If a disease be contagious, it must be so by virtue of a mate- 
rial, or essence produced in and evolved from the person of an 
individual; and it is averred that A and B may propagate that 
cause from house to house, while C, D and E are admitted to have 
no such power of transmission. A physician has even been called 
a walking pestilence, because he has met with numerous ex- 
amples of puerperal fever in his practice, while his brethren 
have had no such trying occurrences to lament. He has been 
tracked, it is said, by the victims of a contagion transmitted by 
his person. And it is quite true, that we occasionally meet with 
inexplicable instances of the existence of the disease among the 
patients of a single practitioner, or of two or more medical 
people of a city or village, while the other brethren who continue 
their practice in obstetricy, encounter no untoward lying-in cases. 
It is a matter of vast moment to determine the question of the 
contagion, or the non-contagiousness of puerperal fever, a subject 



PUERPERAL FEVER. 583 

most difficult to investigate, and like the question of the contagious- 
ness of plague, of cholera Asiatica, of yellow fever, likely long to 
remain unsettled, after useless discussions and inquiries. It 
would, perhaps, be wrong to say useless, since such inquiries 
lead, in the long run, to the establishment of the truth. 

Having practiced midwifery a great many years, and having 
been concerned in the visitation of the sick laboring under puer- 
peral fever, whether sporadic or epidemic, — visiting the same 
cases with those who have so cruelly been abused, as performing 
the part of a walking pestilence, scattering death and desolation 
where they desired only to do good, — and seeing that I could never 
convict myself of being the means of spreading the contagion, 
I remain incredulous as to the contagiousness of the malady. 
I have gone from the dissection of the bodies of women, dying 
at the hospital, with symptoms of the most violent puerperal 
peritonitis, prevailing epidemically there, and have never commu- 
nicated it to those whom I soon afterwards delivered in their labors. 
I have visited the patients of those, among whose patients the dis- 
ease seemed to extend because they were the attending physicians, 
yet I did not convey the malady into my own clinical practice, 
while they were loudly accused of so doing. 

One of these gentlemen has had the kindness to furnish me 
with a note, in which he relates, that he has carefully examined 
his cases of puerperal fever, and finds that the whole number that 
he attended, amounted to ninety-five, of which there occurred — 
In 1841, .... 3 

" 1842, - ' - - - 9 

" 1843, - 45 

« 1844, - - - - 25 
" 1845, - - - 6 

« 1846, - -■ - 7 

making in all ninety-five. The first case was on the 6th of Sep- 
tember, 1841, and the last on the 6th of June, 1846. Seventy- 
seven recovered, and eighteen of the cases terminated fatally ; of 
which, two were cases of twins, and three were cases of presenta- 
tion of the arm. In eight of the cases, the child was born before 
the gentleman entered the chamber ; and in four the delivers* of 
the placenta had taken place previous to his arrival. 

Dr. Rutter, of this city, to whom I am obliged for the note in 
question, was engaged at that time in a most laborious midwifery 



584 PUERPERAL FEVER. 

practice ; a practice, for which he is eminently qualified, by his 
knowledge, skill, and temper. The result of his practice during 
a disastrous epidemic might be taken as proof of his ability, for he 
lost only eighteen out of ninety-five patients, or one in five and a 
half; and that, in a class of cases that were characterized by the 
utmost intensity of violence, as I can bear witness, having seen 
some of them along with him. During the prevalence of the same 
epidemic at the Dublin Lying-in Hospital, while the distinguished 
Dr. Robert Collins was Master of the hospital, eighty-eight cases 
occurred. Of these eighty-eight cases, fifty-six proved fatal, 
which is equal to the loss of two out of every three cases, and that, 
too, under the watchful care of the most scrupulous and consci- 
entious assistants, directed by a person of such high medical ability. 

Gordon, up to the time of changing his mode of treatment, lost 
one in two of his patients;, and the younger Hey, of Leeds, had a 
success not so good as this, until after he had discovered the 
Gordonian theory of the treatment of puerperal fever. Hey lost 
eight out often. 

My friend Dr. Rutter, informs me, that to one of the cases, he 
was summoned on the night of his return to the city, after an ab- 
sence from it often days, at a distance of thirty-five miles. Pre- 
vious to visiting the patient, he entered a warm bath, had his head 
shaved, put on a new wig, new hat, new boots, and pocket handker- 
chief, and every article of his dress was bought new for the occa- 
sion ; leaving at home even his watch and pencil, and taking care, 
after the bath, not to touch a single article of the clothing he had 
previously worn. The patient whom he attended, was immediately 
seized with the symptoms of puerperal fever. I was called to see 
her along with him, and attended her up to the period of her death, 
which took place on the eleventh day after the birth of the child. 

Two years later, in 1846, he resorted to the same precautionary 
means, before taking charge of the case, which being seized with 
the disease, likewise terminated fatally. 

Eleven of the children born in the ninety-five births, died with 
erysipelas, commencing at the umbilicus, after the mother had 
succumbed to the malady; and four others perished in the same 
way, while the mother recovered from the attack. 

If the malady, which many of my brethren in this city, sup- 
posed to have been propagated by the gentleman in question, had 
really been transmitted through his person, how shall we account 



PUERPERAL FEVER. 585 

for its attacking those women whose labor terminated previous to 
his arrival ; or how shall we explain the exemption not only of 
many of his own patients, but of mine also, and those of other 
physicians called by him in consultation, from the influence of 
a contagion so direful. Would it not be more philosophical 
to say, that one of those strange fatalities that are often found 
to occur, had brought him into contact with the cases of women 
ill, whereas his neighbors, and fellow practitioners, more fortu- 
nate than he, met only with the ordinary phenomena accompany- 
ing the lying-in state. 

Another gentleman, a friend of mine here, who, during the 
prevalence of the same epidemic, unfortunately met with nume- 
rous violent and fatal cases, was also supposed by many persons 
to have carried the poison about his person. On one occasion he 
invited me to see an individual laboring under the malady, in the 
district of Kensington. She was moribund at the time of my 
visit; and while deploring the event, he pointed out to me a house 
at no great distance, in which he had, shortly before, lost a patient 
laboring under the same malady. He informed me that the per- 
son in question, whom he was accustomed to attend in her con- 
finements, had engaged him to be present at her expected ac- 
couchement; but having been rendered anxious by the late sad 
events of his practice in the existing epidemic, and hearing nothing 
from her at the time proposed, he had called at her door to ask 
after her health. He was informed that she had been confined two 
days previously, but so suddenly, and with so little difficulty, 
that, they had not thought it necessary to notify him, or give 
him the trouble to call. He was told she was now indisposed, 
and invited to see her; whereupon he entered her chamber, and 
found that the case, one of puerperal fever, had gone beyond the 
curable stages. So that she was added to the catalogue of the 
victims of this walking pestilence. You see how unjust it is, in 
making up the list of fatalities in the doctor's practice in the epi- 
demic, to put down such a case as this among the victims of con- 
tagion. 

Dr. Collins, at page 387 of " The Practical Treatise on Mid- 
wifery," informs us that in 1829, when he was Master of the 
Dublin Lying-in Hospital, puerperal fever, which, for several 
months previous had prevailed there, increased much in intensity. 
Upon consulting with the medical committee, it was recommended 



586 PUERPERAL FEVER. 

that no patient, except the absolutely destitute, be admitted ; but 
that assistance be afforded at their own homes. He then had all 
the wards, in rotation, filled with very condensed chlorine gas for 
forty-eight hours ; the windows and all openings being carefully 
closed. The floor and wood work were then covered with chloride 
of lime of the consistence of cream, left on forty-eight hours; after 
this, the wood work was painted, and the walls and ceiling 
washed with fresh lime. The blankets, &c, were scoured, and 
all stoved in a temperature of from 120° to 130°. From this 
time, until the termination of his Mastership, in November, 1833, 
that is, a period of fifty-seven months, he did not lose a single 
patient by the disease. 

These facts are strongly calculated even to prove that the 
fever derived its origin from some local cause, and not from any- 
thing noxious in the atmosphere. To this, Dr. Collins says he 
should assent, was not the evidence equally strong of its existence 
in the houses of the rich. 

The prize work, by the younger Baudelocque, entitled, " Traite 
de la Peritonite Puerperale" a work of the greatest value, contains 
at page 127 Dr. Baudelocque's observations of the subject of the 
contagiousness of the malady. He speaks of the difficulty of dis- 
criminating the epidemic from the contagious character of a dis- 
ease, which is as true of epidemic puerperal fever as of any other 
epidemic ; and thinks, in the present state of our knowledge, it is 
impossible to decide as to the contagiousness of our malady. But 
notwithstanding the sentiments of the English physicians, Joseph 
and John Clarke, he inclines to the opinion of the non-contagion- 
ists, and cites Mr. Duges, who states that he has never known a 
case in which an eleve-sage-femme, charged in the hospital with 
the cases of two women confined, had carried the disease from a 
sick to a healthy woman : nor, has he ever known the disease to 
be propagated from bed to bed in the ranges of wards appropriated 
to healthy women. 

M. Baudelocque looks upon these facts as opposed to the doc- 
trine of contagion, yet as not settling the question ; and it would 
be presumptuous, he thinks, to affirm that there is no conta- 
giousness; and, disbelieving in contagion, he should hold himself 
bound to act in any case as if contagion were possible. 

Dr. Robert Lee, at page 492 of his "Lectures on the Theory 
and Practice of Midwifery" expresses the opinion that it is our 



PUERPERAL FEVER. 587 

duty to act, in all cases, as if the contagious nature of the disease 
had been completely demonstrated. You ought to read Dr. Lee's 
thirty-ninth lecture, beginning at page 487, which is an excellent 
examination of the causes of inflammation of the uterus and its 
appendages in puerperal women. I fear that the cases he has 
recited may tend to establish in your mind the doctrine of the 
contagiousness of the malady. Nothing has yet served to con- 
vince me that it is transmitted by a physician or nurse ; yet, not- 
withstanding such an opinion, I cannot wholly divest myself of a 
feeling of obligation to take the most especial care not to be the 
agent of its transmission, under the supposition that the contagion- 
ists possibly are right, and the non-contagionists possibly in error. 
It is an incontestable fact, whether the disease be contagious or 
not, that one midwifery practitioner is liable to meet with numer- 
ous cases in his practice, while his brethren, equally engaged in 
the same streets, villages, towns, or districts, — shall meet with 
no cases at all. This was remarkably the case in the epidemic 
at Aberdeen, the history of which is related by Alexander Gordon. 
Dr. Armstrong tells us, that forty out of fifty-three cases observed 
in Sunderland, occurred in the practice of one surgeon and his 
assistant. 

Gordon looked upon it as contagious ; and he considered that 
every person who had been with a patient with puerperal fever, 
became imbued with an atmosphere of infection, which was com- 
municated to every pregnant woman who happened to come 
within its sphere. — Vide, -page 51, of the Philadelphia Ed., 1842. 

If you insist upon it, that the cases, like those of my friend 
Dr. Rutter, and those referred to by Dr. Armstrong, were com- 
municated by contagion, you will be compelled to say, that the 
constitution or the clothing of one individual has some peculiarity 
which enables him to carry the fomites wherever he goes; while 
those of another person, apparently in the same state of health, and 
with a similar dress, is wholly incapable of transmitting it. This 
is a fact, and I conceive it to be an unanswerable one. I have 
proved it in my own case, over and over again, since I have gone 
from the houses of persons laboring under the most malignant 
forms of the disease, and from participating in necroscopic exami- 
nations without carrying the malady with me. 

If you should assert that a medical man may generate the. 
fomites of our disease in his own constitution, without being 



588 PUERPERAL FEVER. 

at the same time subject to any manifest signs of the malady 
himself, you will arrive at a conclusion far more probable than 
that of the contagiousness of this, generally speaking, serous 
malady. 

I find an insuperable objection to the admission of its conta- 
giousness in the serous character of the malady, since the conta- 
gious maladies are, all of them, either mucous or dermal affections : 
it is true, that some of the cases of gangrenous metritis that we 
meet with, affect the mucous surface of the womb, if it hath one, 
which is still a subject of dispute among authors. I am more in- 
clined then, to reject the doctrine of the contagiousness of these 
maladies; and to look upon the occurrences that have gone so far 
to establish, in some men's minds, the opinion of its personal trans- 
missibility, as to be explained upon the doctrine of accidents. It 
is a fact, that accidents happen in groups : very frequently rail- 
road accidents happen in groups; numerous accidents at saw- 
mills happen in groups; accidents or murders from fire-arms 
occur in groups; fractures of the limbs occur in groups, without 
any known connection between the number of individuals who 
suffer or the occasions which bring about the results. 

From all the foregoing, you will perceive, my young friends, 
that I assert my disbelief in the contagiousness of the various 
forms of disease that are grouped together under the title of puer- 
peral or child-bed fever; and you will have noticed at the same 
time, that, notwithstanding my plenary assertion of this disbelief, 
I am not able to fly in the face of the assertions, and opinions, 
and sentiments, of many of my medical brethren, worthy of my 
highest respect; so that, in fact, I do not feel at liberty to disobey 
their injunctions, as to taking all proper precautions against pro- 
pagating by my person, a malady so fatal in its nature. And I 
therefore most explicitly declare, and I beg you to bear in mind 
that I make this declaration, that I think it will always be your 
duty, whether you may believe in the contagiousness or not, of a 
malady, to avoid, as far as it may be in your power, all occasion 
to transmit, if it can be transmitted, this epidemical or endemical 
disorder. 

It has often been observed, that the cases of puerperal fever 
have been particularly rife at the same time that there has been 
a considerable prevalence of erysipelatous diseases ; and you 
will often hear in conversation, and you will observe sometimes 



PUERPERAL FEVER. 589 

in your reading, that there is some connection asserted to exist 
between the nature of erysipelas and that of puerperal fever ; and 
further, that there is an identity in the causes which produce them. 

In the Lying-in wards of our Pennsylvania Hospital, where 
puerperal fever has been repeatedly prevalent, it has been noticed, 
that numerous individuals laboring under wounds, whether from 
accidents or from surgical operations, have at the same period of 
time been laboring under erysipelas ; and, it has become a sort of 
custom of the house, to fear the outbreak of puerperal fever in our 
lying-in wards, whenever a remarkable rifeness of erysipelatous 
action is observed in the Surgery. Nevertheless, it is absolutely 
true, that erysipelas frequently prevails in the Surgery when there 
is no puerperal fever among the women confined in the estab- 
lishment. 

Erysipelas is a disease of the skin ; I have no doubt that erysi- 
pelas is always an inflammation of the capillaries of the skin — it 
is always an angeio-leucite ; and although it is occasionally found 
to descend into the tissues lying beneath the skin, converting 
itself into what is called cedematous erysipelas, and perpetrating 
the most direful mischief in the cellular and adipose structures 
there, it is essentially a dermal disease, and can only affect the 
dermal structure. You might as well say, that a woman has an 
iritis of her pylorus, which would be absolute nonsense, since no 
such tissue exists there, as to say, that she has an erysipelas of 
the serous lining of her belly. It might be perfectly true, that 
she has erysipelas of her vagina, or an erysipelas of the lining 
membrane of her womb, — if she has one — a question still sub 
judice, — because, a mucous tissue is nothing more or less than a 
true skin turned inwards. Mucous textures and dermal are con- 
vertible terms ; skin may be converted into mucous membrane, 
and mucous membrane may be converted into skin, in one in- 
stance by bathing it in fluids, in the other by exposing it to the 
drying influence of the atmosphere. You will find the proof of 
this in the cases' of chronic prolapsus uteri, or inversion of the 
vagina, met with in practice. 

There is not, and cannot be any identity between erysipelas, 
a dermal disease, and the deadly inflammation of the peritoneum 
observed in lying-in women; notwithstanding there may be some 
coincidence in the causes which, in the first case, render surgical 
patients liable to erysipelas, or in the other, lying-in women to 
the attacks of child-bed fever. 



590 PUERPERAL FEVER. 

The fallacy in the case arises from this; both erysipelas and peri- 
toneal and pleuritic inflammation are membranous maladies; in 
general, not extending beneath the subcutaneous and sub-serous 
textures ; and people have supposed, because they are membra- 
nous maladies, and are liable to spread along the surface of mem- 
branes, that they are all erysipelatous. If you choose to say, 
gentlemen, that every disease that spreads far and wide over a 
membrane is erysipelatous, I have no objection to your calling it 
so. But, I beg you to observe, that, in that case the duty will 
devolve upon you, of furnishing some new theory of the patholo- 
gical lesions in our malady, which in some of the most deplorable 
instances exhibits no signs whatever of membranous disease, 
but proceeds to destroy the patient at once, by a process of spha- 
celation, or ramollissement of the newly delivered uterus, reducing 
it in the space of six-and-thirty, or eight- and-forty hours, to a 
condition of softness so complete, that a man's finger may be thrust 
through it as through a pudding. 

You had better say, therefore, that the disease is not erysipe- 
latous, but that when erysipelas is epidemic, or endemical, the 
persons who are to be confined, ought to take special care of 
themselves, since any intemperies of the air giving a tendency 
to erysipelatous inflammation, exposes the accouche to attacks of 
puerperal inflammation. This is not less true of the prevalence 
of typhus, of small-pox, or other great epidemic maladies, whose 
domination is so universal, that they compel all manner of diseases 
and diseased propensities to come beneath their sway. 

There formerly lived at Aberdeen, in Scotland, a gentleman by 
the name of Alexander Gordon, whose name I have already men- 
tioned in this letter, and who enjoyed an extensive practice 
there, and in the country round about, and was a man of distin- 
guished ability, probity, and consideration. 

Dr. Gordon encountered an epidemic of puerperal fever, in and 
about Aberdeen, in the end of December, 1789, which continued 
to prevail epidemically in that region, until the month of Octo- 
ber, 1792. In this epidemic, he attended seventy-seven persons, 
of whom there died twenty- eight, according to his Table, which 
you will find at page 36 of his book, entitled A Treatise on the 
Epidemic Puerperal Fever of Aberdeen, &c. 

"It prevailed," he says, "principally among the lower classes 
of women," and, on account of his public office, and his exten- 



PUERPERAL FEVER. 591 

sive practice of midwifery, most of the cases came under his care. 
The disease, at the time of its onset, was new and unknown at 
Aberdeen. Dr. Gordon was unacquainted with its real nature ; 
and out of the first twenty persons that he attended, from Decem- 
ber 1789, to October 1790, he lost eleven, more than one-half of 
the cases; because he treated those cases without energy, and 
without intelligence. Having been taught, by woful experience, 
the inadequacy of his method; and having enlightened his mind 
by the dissection of a few of the early victims, he adopted a 
more energetic practice, founded upon the substantial proofs of 
phlogistic action, revealed by the necroscopic inquiries. 

Dr. Gordon's volume is a small, unobtrusive book, written with- 
out arrogance or pretension: it is a plain, round, unvarnished 
tale ; being a history of his concern with the epidemic ; and car- 
ries so convincing and truthful an air into every page and line, 
that I cannot imagine anything better fitted to impress the mind 
of the reader with the w T arm and intense convictions of the writer. 
Half a century has elapsed since it appeared, and it is always 
quoted, or referred to, in treatises on the same subject; and never 
loses its good and solid reputation. Every medical practitioner, 
whether accoucheur or not, ought to read it with care ; and I am 
almost ready to say, that its perusal is indispensable to a right 
understanding of the history, nature, and treatment of puerperal 
peritonitis, — not that I intend to declare that Dr. Gordon's obser- 
vations, whether therapeutical or necroscopical, were sufficient to 
make plain the whole nature of the malady ; but, that if a man 
take up the modern books only, there will be in his notions of the 
subject, a void, as to its literary history, and the history of its 
treatment, that no other book than Gordon's can fill. 

Whatever critics may please to say of Dr. Gordon's perform- 
ance ; however wofully they may have erred in their theory and 
practice in our malady ; Gordon must ever be regarded as^the re- 
former of our therapeutics in child-bed fever: nor can it be denied, 
that since his publication, there is universally diffused a more 
perfect and sensible conviction of the inflammatory character of 
the disorder, and, what is of far greater consequence, the little re- 
gard that need be paid to the state of the pulse, in making up one's 
mind as to the necessity of treating it boldly in its curative stages. 
I say this even in view of Tonnelle's celebrated papers. 

Gordon had neither leisure nor privileges for making numerous 



592 PUERPERAL FEVER. 

or elaborate dissections; that task has been well fulfilled, emi- 
nently well, by Robert Lee, of London, in his Treatise on Puerpe- 
ral Fever and Crural Phlebitis, which you will find at the 21st 
page of Barrington and Haswell's edition, before cited. It has 
also been admirably performed by Tonnelle, and others. All the 
researches since his time, have but added strength to the patho- 
logical explanations, that are first to be sought for in Gordon's 
volume. The newer and more minute essays, which proceed so 
much farther than Gordon had gone, ought to be studied by every 
one of you; for, I do not believe, that the writings of Hey, of the 
younger Baudelocque, of Armstrong, of Mackintosh and Lee, of 
Legouais, or Collins, combined together, could carry such a 
weight of conviction to the mind of the reader, as the perusal of 
them after the study of Gordon's would do. Gordon is the first 
of the series, and the others wait on him, and honor themselves 
by illustrating him and their subject, in confessing their obliga- 
tions to the practitioner of Aberdeen. 

If it were in my power, gentlemen, to put into the hands of 
every member of the class, a copy of Barrington and Haswell's 
volume, I would not take the trouble to write this letter; for I 
believe, that a study of that volume alone — I don't say merely the 
reading of it, but a careful study and a conscientious examination 
of that volume alone — is enough for a man's education on the 
subject of child-bed fever, whether sporadic or epidemic. 

The pregnant woman approaching the time of utero-gestation, 
may be supposed, in general, to undergo many modifications as 
to the crasis of her blood, and to suffer no inconsiderable changes 
in regard to the recrementitial absorptions of her body, since the 
pressure, intrusion, and distension of important textures, all com- 
bined, cannot fail signally to interfere at many points, with the 
innervative, assimilative, secretory, and absorbing functions. I 
think it would not be extravagant to say, that few women march 
up to the termination of pregnancy, without falling into a state, 
deserving to be called pathological. "When the child has been 
born, — often after the most cruel sufferings and the most protracted 
exertion ; amidst the most convulsive efforts of the will ; amidst 
doubt, anxiety and fear, — the uterus, returning upon itself, has- 
tens to recover its non-gravid form and dimensions, leaving the 
constitution under the necessity of disposing of the surplus fluids 
and solid parts, which the pregnancy had called into existence. 



PUERPERAL FEVER. 593 

Tissues have been pressed together, subjected to contusions, and 
often to slight and unsuspected fractures, or lacerations ; the pla- 
cental orifices of the uterine sinuses are left bleeding and recover- 
ing; so that thousands and thousands of provocations to sanguine 
engorgements and acute inflammations, always exist as to them. 
You will find a picture strongly drawn at the 475th page of 
"Archives Generates" t. 22, 1830, by Tonnelle, in which it is 
made manifest that gestation and parturition produce in the con- 
stitution effects not very dissimilar from those produced by the 
causes of typhus fever. 

It is justly to be regarded as a matter of wonder, that so many 
thousands of women escape unharmed the operation of these un- 
favorable influences; nor should we be surprised when we meet 
with persons, in whom violent disease has been developed by the 
operation of such causes. In particular, ought we to feel no as- 
tonishment, if an aerial cause, having the potency of an epidemic 
principle, come to add its force to the personal ones just enume- 
rated. 

We ought, then, to regard a newly-delivered woman as by no 
means freed from the perils of child-birth, because her child has 
just been born. In fact, so few women die in labor, or in conse- 
quence of direct injury done to the economy in labor, that it might 
almost be said, to be not at all dangerous to go through that pro- 
cess. The child-bed mortality is a post-parturient mortality, con- 
sisting mainly in the results of inflammatory action attacking the 
reproductive tissues, and the parts directly connected with them. 
A woman will now and then be found to perish from inflammation 
of the lungs ; from a cerebritis ; from an attack of diarrhoea ; from 
a bilious, or typhus fever, or some chronic ailment of the intesti- 
nal tube, forced into destructive activity by the parturient circum- 
stances ; and yet it is almost true to say, that when a woman dies 
within some eight or ten days after delivery, she has perished 
with puerperal fever, since so few of them are known to perish 
from other causes. 

There is sufficient evidence of the fact, that occult causes, 
whether atmospheric or local, are capable of so impressing the 
human economy as to give it a tendency, when affected by mor- 
bific powers, to exhibit the effects of such forces, under taxic on 
the one hand, and on the other under ataxic forms. Thus, for a 
38 



594 PUERPERAL FEVER. 

series of years, the lancet, and the most powerful antiphlogistic 
methods are generally adopted by the profession; whereas, another 
series shall succeed, during which such methods come to be pro- 
scribed, and generally, at last, abandoned by our people. If, 
then, puerperal fever be a true inflammation, that inflammation 
may be a very different sort of malady, when occurring in a con- 
stitution prone to ataxic forms of disease, from the same inflam- 
mation attacking an individual in a highly phlogistic and reactive 
condition of life. — The local disorders always take their tenden- 
cies from the state of the whole nerve force ; and an inflammation 
of the womb, or of the peritoneum, may be either in the highest 
degree vigorous, or to the last degree typhous in its nature. 
The inflammation, however, always remains essentially the same 
malady, when regarded as local — the constitutional disturbances 
flowing out of it are widely different, in the two opposite, or taxic 
and ataxic formulae. 

All the necroscopic examinations concur to show, that puer- 
peral fever is a febrile disease developed in the system from cer- 
tain points of local inflammation of the reproductive organs. A 
puerperal fever that proves fatal, and leaves no trace of inflam- 
mation demonstrable by the necroscopic inquiry, ceases from that 
moment to have, in my opinion, the value of puerperal fever ; it 
is something else. I do not mean to say, that if you examine the 
body of a female who has died, as you suppose, of puerperal 
fever, and find no gangrene or softening of the uterus, no inflam- 
mation or deposits within the belly, you are, therefore, to sup- 
pose that you have been mistaken in your diagnostic ; you will 
find in the pathological records, abundance of examples of the 
absence of these traces. But, these very cases, being those of 
persons who have perished with all the constant signs of our 
malady, are cases of endangial disease affecting the vessels of the 
uterus and parts in its vicinity: endangial disease, running early 
to the extent of pus production, or to the pyogenic extent, may 
rapidly destroy the patient from purulent infection of the whole 
mass of the blood. I have no doubt, that some of M. Tonnelle's 
cases were of this very kind. 

The attack of puerperal fever generally begins previous to the 
fourth day after delivery of the child ; not a few examples are re- 
corded, in which it began previous to the labor. I have seen such 
a case myself. For the most part, the dangerous day is the third 



PUERPERAL FEVER. 595 

day, for that is the period at which the new fluxional movement 
towards the mammary glands begins to take place. If the occa- 
sional causes of the disease have been in action, this fluxional 
movement, itself alone, might become sufficient to act as the 
exciting cause ; laying the foundation, perhaps, in a few moments 
of active operation, of an inflammation that shall spread with 
frightful rapidity throughout the most important textures. 

It rarely happens that an attack of puerperal fever comes on, in 
the absence of the physician, without its being mistaken for an 
after-pain ; and, in fact, the pain at the commencement is accom- 
panied with alternations of increased and lessening distress, which 
is likely to mislead in the diagnostic. 

If the irritation is intense at the commencement, its constitu- 
tional influence is manifested by rigors, that may be simply mode- 
rate rigors, or that may rise to the height of the most violent 
ague-fit. The chill may last twenty minutes, or two hours, or 
more, and is followed by febrile reaction more or less open and 
free, according as the powers of the nervous system shall be able 
to direct a greater or less energy upon the sources of the circu- 
lation. The chill of puerperal fever is found, in some instances, 
to precede the attack of pain, from which you are not to conclude 
that the chill is the cause of the attack, because, it is certainly 
true, that the sensitive cords of a part attacked, are not always 
capable of transmitting to the sensorium, evidences of the distress 
of the organs to which they are distributed. The disorder, the 
irritation, the maladive condition, may, nevertheless, be capable 
of compelling those reflex actions of the nervous system, that are 
required to produce rigor, chill, or even ague. 

A woman who is to be attacked with puerperal fever, is a 
woman in health, — or rather in a state of quasi health; she has 
not small-pox, nor Syrian plague, nor yellow fever, though she 
may have a proneness to fall ill with what you call child-bed 
fever. If you fire a bullet through her womb, or tear it, or con- 
tuse it with a pair of forceps or a sharp crotchet, and she die of 
the inflammation resulting from the accident, she will die of puer- 
peral fever. And so, if from the intense irritation endured by the 
organ under after-pains; if from the impetuous momentum of 
torrents of blood determined upon its tissue during a rigor or an 
ague consequent upon swallowing a tumbler of iced w r ater, or of 
getting out of bed w T hile in a state of perspiration ; or of the intern- 



596 PUERPERAL FEVER. 

pestive action of a drastic purgative dose ; or if, from whatsoever 
cause, the blood-vessel system of the uterus becomes the seat of 
a local inflammation, that inflammation will determine in her the 
onset of child-bed fever, which you will denominate uterine phle- 
bitis, metro-peritonitis, ovaritis, simple peritonitis, or inflammation 
of the lymphatics of the uterus, according as the phenomena 
clearly made manifest during the life of the patient, or upon ex- 
amination after death, shall determine you to call it. Don't you 
see, my dear friends, how impossible it is for me, after writing 
the above paragraph, to admit the possibility of a specific con- 
tagion as the cause of this malady; a contagion, which, if it do 
exist, must, in a thousand instances, act without the intervention 
of the shortest imaginable incubative stage. 

Sometimes the pain, which is, at the onset of puerperal fever, 
felt in the hypogastric region, is too intense to be borne by any 
human patience ; and no exhortation or recommendation, can 
prevent the woman from crying out aloud, or even screaming with 
her agony. I have seen patients, who not only appeared to suffer 
intolerable pain, but in whose minds that pain appeared to excite 
the most unspeakable terror. I think I have seen women who 
appeared to be awe-struck with the dreadful force of their distress, 
as you might imagine an ancient Roman matron to be, who might 
suppose such a pain to be inflicted by an ictus Jovis, the anger of 
the Gods. The pain, however, soon loses a portion of its inten- 
sity, and no doubt much of the earliest and sharpest pain is neu- 
ralgic, since it is not in the nature of pure inflammation to occa- 
sion such great sufferings. 

The paroxysmal character of the disease, in metritis, must be 
deemed to be occasioned by a convulsive «r spasmodic constriction 
of the inflamed tissues, under the irregular activity of the muscu- 
lar fibres of the organ, which soon ceases, allowing the pain to 
become more settled, steady, and bearable. 

If there be a chill, there will be found, as in all chills, in- 
creased frequency of the heart's action ; the systole comes in a 
very short time, to be repeated, at the rate of 120 or even 
160 beats per minute. This is necessarily accompanied with 
congenerous modification of the action of the respiratory muscles, 
and there is no part of the whole economy of the creature, 
throughout which the blood is not driven with an impetuous 
haste and force. But the brain cannot receive such modified 



PUERPERAL FEVER. 597 

injections of the blood, and of the oxygen of the blood, upon 
which depends its power to evolve neurosity, without irradiating 
its nerve power morbidly to every part and parcel of the tissues, 
of which she is composed. So that you see, gentlemen, there is 
no occasion to be surprised or astonished, when, after having left 
your patient at ten o'clock in the evening, comfortable, and ap- 
parently without any untoward symptom or accident, you find 
her, at six in the morning, a prey to the most unspeakable dis- 
orders of the innervation, the respiration, and the circulation. 

The foregoing is sufficient to set forth my opinion as to the 
nature and beginning of the attack of child-bed fever. To show 
you what may be the organs involved in the ravages of a disease 
thus commencing, I shall cite for you some passages from Ton- 
nelle's paper, op. citat., page 482. 

This author, in the great epidemic which he witnessed at the 
Maternite in Paris, when he acted as resident student there, under 
the guidance of the great Prof. Desormeaux, had the extraordi- 
nary opportunity, but still more wonderful industry, to dissect 
the bodies of two hundred and twenty-four women who died 
under his care; — more than perished at Contreras, Churubusco, 
or Chapultepec. He gives the following tables showing the tis- 
sues affected : 

193 gave peritonitis. 

197 gave disease, apparently of the womb. 

4 represents the excess of the uterine cases over the cases 
of peritonitis. 
Table of one hundred and ninety cases, which gave — 
79 of simple peritonitis. 
29 of superficial ramollissement of the womb. 
20 of deep-seated ramollissement of the womb. 
58 of inflammation of the ovaries. 
4 of inflammation of the ovaries, with abscess. 
Table, showing that 

90 cases gave pus in the veins. 
32 " gave pus in the lymphatics. 
3 " gave pus in the thoracic duct. 
9 " gave inflammation and suppuration of the lum- 
bar, inguinal, and other glands. 
The whole epidemic was characterized by three formulas of 
puerperal fever, as follows: — 



598 PUERPERAL FEYER. 

Inflammatory, or simple inflam- C The peritoneum, the womb, and its 
mation of different organs. } appendages. 



Typhoid form, or from altera 

tions of the blood. 

I lissement. 



Consecutive suppuration of the veins : 
-{ or, accompanying putrescence or ramol- 



Ataxic form, or lesions of the innervation. 

Now, this is sufficient to set forth in a clear manner, as far as 
it goes, the doctrines you ought to adopt as to the pathological 
seats of our disease ; and let us therefore proceed to trace the 
effects of it. 

Let us suppose that it is one of the peritoneal cases; a case in 
which the peritoneal surface of the womb, of one or both of the 
broad ligaments, or of an ovarium, is the radiant point, the first 
red specked point of inflammation. Suppose the inflammation to 
extend upon the intestines, to attack the meso-rectum, the peri- 
toneum covering the iliacus internus, the mesentery, the whole 
peritoneal coat of the smaller intestines and the omentum, — the 
mesocolon and the colon — the stomach, the peritoneal coat of the 
liver, and the entire lining of the diaphragm, as well as of the 
kidneys and spleen; and then you will have an idea of a woman 
laboring in the lying-in state under a universal peritoneal inflam- 
mation. 

Consider, now, that she has passed through the whole of the 
evolutions of a nine months' gestation ; through the convulsion, 
intellectual, physical and moral — of the conflict of labor ; and, to 
a certain extent, through the mutations of her constitution conse- 
quent upon delivery; her blood deranged as to its crasis; her 
neurine exhausted by protracted exertion of its functional power, 
and her whole endangium in a condition in which it is highly 
prone to take on, if it have not already fallen into a pathological 
state. 

What is the condition of your patient? Has she not hepatitis? 
Has she not a pure hepatitis, whose whole peritoneal surface of 
the liver, is inflamed? If the whole outer superficies of your 
stomach is in a state of incandescent inflammation, have you not 
a gastritis ? But suppose her mesocolon, her mesentery, her 
meso-rectum, her ligamenta lata all burning, like a prairie on 
fire; are not all these parts in a state of inflammation? And if 
they be, what wonder have you to find her whole nervous system 
shocked, overwhelmed, staggering, as under a concussion, and 



PUERPERAL FEVER. 599 

crushed to death by a load of diseased perceptions and vascular 
and textural obstructions impossible to be borne? 

This is a picture, not at all exaggerated, of some of the forms of 
puerperal fever. An individual is very tenacious of life, who fails 
to succumb under the earlier stages of the maladive progress of 
the inflammation. There are multitudes who die before it can 
come to such a pass; but it must come to such a pass in many of 
those whose peritoneal cavity is found to contain pints or quarts 
of serum, in which float masses of coagulated albumen, while 
the uterus and intestines and peritoneal surfaces, are tied to- 
gether by a complete magma of coagulable lymph, beneath 
which are to be found softening of the tissues, and other results 
of the most intense inflammatory action. Inflammation is inflam- 
mation; it is not weakness or debility; it is development force, 
violently exaggerated in the tissue which is the subject of that 
force. 

I pray you, young gentlemen, do me the favor to turn back to 
Letter 21st, and you will find on the 267th page, my quotation 
of several paragraphs from M. Serres 5 " Anatomie Trans cendente." 
If you mean to read my letter on puerperal fever, I am very de- 
sirous that you should appreciate my meaning and intent, and 
the reading of M. Serres' extract will be a good preparation 
therefor. It will show you that the products of inflammation are 
the products of a force, acting in progression, and not in retreat, 
and that inflammation is the result of an increased action of the 
development force, tearing or bursting to pieces the organs in 
which it revels. 

Let us take another case ; let us suppose a case, in which the 
endangial membrane of the uterine veins begins to be inflamed 
at their orifices, which are patent upon the now denuded placental 
surface, and, progressing rapidly along the membrane, involves 
the whole vascular system of the uterine sinuses and veins in its 
embrace. 

Look at it now. Can't you see it with the eye of faith? What 
is faith? The Bible tells you that faith is the evidence of things 
not seen. Have you not that evidence? Look at Tonnelle's 
paper, op. citat., page 483. 

His table is as follows: — In ninety autopsies 

32 had suppuration of the veins, with purulent degenera- 
tion of the uterus. 



600 PUERPERAL FEVER. 

11 had ramollescence or putrescence of the womb. 

5 had metritis and ramollescence combined. 
34 had peritonitis without other alteration. 
8 had suppuration alone. 

Here is the evidence, which your faith ought to see, of the state 
of suppuration of the veins, — a result of inflammation of the en- 
dangial tissues. Thirty-two out of ninety cases. 

Look at it again. Don't you see two vast uterine arteries, 
coming off from the internal iliac or the ischiadic? And don't you 
see, also, two powerful branches, which we call the spermatic, the 
sum of whose transverse areas or lights is a vast sum, through 
which is pouring, under the convulsive and disordered action of 
the systole, a torrent of blood to fill up the capillary circulation 
of the uterus, and which shall find no other way of escaping out 
of the womb, than through the thickened, swollen, obstructed, 
and often totally obliterated tubes, of which I spoke? 

If you would read M. Raciborski's admirable Treatise on the 
Veins, you would learn from it that a vein, when it enters a vis- 
cus, leaves all its accessory coats at the entrance, and carries with 
it nothing but its endangium, or what Bichat calls its membrane 
commune. If this be the case in the vein-distribution within the 
womb, then you cannot doubt that uterine phlebitis will always 
be coincident with metritis — that is, with inflammation of some 
part of the substance of the uterine texture. 

Look again — with your eye of faith — I say, and inquire how the 
volumes and torrents of blood that are becoming more and more 
packed and jammed into the capillary body of the organ are to 
flow off and let the organ recover by Mr. John Hunter's process 
of resolution. Suppose it cannot flow off as fast as it arrives — will 
not the womb die? — w T ill not the inflammation reach that height 
and intenseness, that must, as Dr. Physick used to tell us, trans- 
cend the power of recovery, and must therefore end in the de- 
struction or disorganization of the tissue ! It will be destroyed, 
it will be disorganized — it will perish by gangrene, or by ramol- 
lissement, which virtually is the same thing, expressed in different 
words. The womb will die, and the woman will die in conse- 
quence ; for she cannot continue to live, while her nervous system 
suffers the shock or the irritation attending upon such an intolera- 
ble organic perception as that. She will die, and it will not un- 
frequently happen that she shall die within thirty- six or forty-eight 



PUERPERAL FEVER. 601 

hours from the onset of the malady. She may die with this very 
malady alone; and when you come to explore the pathological 
lesions, you will find, perhaps, as in the ninety cases reported by 
Tonnelle, that eight of them exhibit no complication or extension 
of diseased action. 

You must cure these diseases: they are to be cured, however, 
promptly, or not at all. Such a malady as this hurries with hot 
and furious haste to the term, beyond which there is not, and can- 
not be any useful Therapia. 

But it is time, gentlemen, to return to the consideration of some 
of the phenomena that accompany the malady w T hen it is compli- 
cated with, or consists solely of peritoneal inflammation. The 
disorder attacks, in general, before the end of the fourth day. The 
womb remains, up to that period, very large; its fundus jutting 
far above the plane of the superior strait. Upon each side of the 
organ rests a psoas muscle, which overhangs, by its inner margin, 
the side of the brim of the pelvis. When this muscle is con- 
tracted, which is always done in the act of drawing up the knees, 
the belly of the muscle swells, and presses upon the side of the 
womb; the pressure gives pain, and the woman knows it. She 
therefore dislikes to draw up the knees often, for fear of the hurt. 
When once drawn up, however, by the contractile effort of the 
psoas, the foot rests planted on the bed, and the psoas relaxes — 
so that it hurts her less when drawn up, than when extended. 
She soon instinctively draws up her knees, therefore, and keeps 
them up. 

When you go into a lying-in chamber, and find 'the patient in 
this attitude, you ought to inquire why she prefers it. She may 
prefer it because the uterus is less compressed by the psoas ; and 
also, because the peritoneal covering of the psose being inflamed, 
is relaxed by the relaxation of the muscles. 

For many years past, I have perhaps never called upon one of 
my accouchees within four or five days after the delivery, without 
asking her to show me whether she could draw up her knees 
without pain. If she can do so, I am always content. 

The iliacus internus muscle that lies upon the fossa or venter 
of the ilium, gives pain if contracted, when the peritoneum that, 
invests it is inflamed. Hence I cause my patient to rotate the 
lower extremity, in order to inquire whether the action of the 



602 PUERPERAL FEVER. 

muscle produces pain, and, if it does not, I cannot deem it co- 
vered by an inflamed peritoneum. 

In all cases of a suspicious character, you ought to direct the 
monthly nurse to remove the binder for you, and then, covering 
the patient's abdomen only with the chemise, give you an oppor- 
tunity to make a careful exploratory palpation of the belly. By 
means of palpation and of percussion, you may come with great 
certainty and confidence, also, to a firm conclusion that the pain 
is, or is not, peritoneal or metritic, or ovaric. 

You cannot make any useful researches, if one or two petti- 
coats, and other garments be interposed between the hand and the 
belly. 

It is very difficult sometimes to say clearly that it is inflamma- 
tion, and not after-pain; or that it is, or is not rheumatism, or 
neuralgia, or colic. 

Suppose the peritonitis to seize on the serous coat of the large 
and small intestines! Tympanites will commence very soon after 
the invasion. The muscles of the bowels are found torpified and 
refraining, under a sort of teleological sense, to act, while their 
peritoneal investment is inflamed. The gases that are now extri- 
cated in great volumes from the ingesta, fill up and distend the 
alimentary tube, and the abdomen becomes as large as previous 
to the labor. This is tympanites. 

I saw a case, and more than one, in which it became inflated 
in the course of a very few hours after the attacking chill had 
come on — and becoming hard and resisting, though highly sonor- 
ous on percussion, refused to yield to any kind of aperient or pur- 
gative means, as completely as if the peristaltic muscles were in 
perfect paralysis — the patient perishing within thirty-six hours. 

Pray, my young friends, do not allow this ballooning of the 
belly to become too great, under some idle fear of the effect of 
purgatives. A patient often more urgently requires to purge off 
the intestinal gases, than the bilious or acid saburra that plague 
her. Whoever objects to the use of purgative doses upon some 
hypothesis of their being injurious in puerperal fever, must be a 
person of little reflection and less judgment. 

An extreme degree of tympany implies an extreme inflation of 
large portions of the intestinal tractus, in which case the coats of 
the bowel become stretched like a drum-head, and are, under per- 
cussion, as sonorous as a tambourine. 



PUERPERAL FEVER. 603 

Reflect for a moment on the effects of such distension upon the 
play of several important functions. For example : reflect upon 
the capillary circulation in the intestinal textures while stretched 
to bursting. — Can there be a resolution obtained without previous 
detente of the bowel? Again. — Here is a great mass of inflamed 
intestines, and other organs that fill up and enormously distend the 
belly — they even thrust the diaphragm upwards as they push the 
abdominal muscles and tegumentary tissues outwards to the size 
of the gravid abdomen at term, and even farther than that. 

Can the diaphragm descend in the aspiration, without crushing 
downwards before it this inflamed and highly sensitive mass? No ! 
Every breath gives pain — to make a long aspiration is impossi- 
ble; and to cough or to sneeze is to be agonized. The diaphragm 
works with short strokes, then; the respiratory piston descends 
only half-way down the cylinder of the trunk, and works like a 
steam piston cut off at half-stroke. In the meantime the oxygen 
is indispensable — and if a certain quantity cannot be supplied by 
the half-stroke, that stroke must be repeated twice, or thrice for 
once. Here, then, we have a new source of disorders in the re- 
doubled and trebled frequency of the respiratory acts. So much 
oxygen — or death — that is the alternative; and, if the breathings 
must be repeated at half-strokes, or at quarter-strokes, at the rate of 
sixty respirations per minute, the medulla oblongata must furnish 
the biotic material. What an exhausting operation ! Here, then, 
you get the hurried, singultiform, staccato respiration of your puer- 
peral fever cases. 

When this respiratory difficulty rises to a certain height — and 
the nervous supply grows feebler and feebler from the exhaustion 
of the neurine — the blood commences to be less perfectly decar- 
bonized, or less completely oxygenated. The oxygeniferous 
streams, in the brain, are changed for carboniferous streams, and, 
pari passu, with their increase the innervations lessen; they cease; 
and the life is fled at the moment of that cessation. Such are 
the evils arising from the tympany of child-bed fever. All the 
medicines that excite the peristaltic muscles of the bowels, to ex- 
pel this gas, are purgatives or laxatives. Is it true, then, that 
purgative medicines are contra-indicated in our malady? — What 
stupid misapprehension to say so! Is it not easy to perceive, 
that one of the most inconvenient and dangerous of the accidents 
that can happen to a female attacked with puerperal peritonitis, 



604 PUERPERAL FEVER. 

is this very inflation of the alimentary tube ; and that the means 
of obviating it, are among the most important that can be sought 
for as securities for the cure of the essential malady — I mean the 
actual inflammation? 

We shall now, if you please, advert to the state of the heart in 
puerperal fever. 

" The nervous filaments that animate the heart, come from the 
pneumogastric and the great sympathetic." These words I have 
cited from Longet's Anatomie et Physiologie du Systeme JYerveux, 
§'c, torn. ii. page 526. I do not ask you, however, to adopt 
any other opinion as to the source of the heart's motion than this, 
viz., that it depends upon the neurosity determined into it, or 
generated within it — and that this same neurosity is the result of 
the existence and combination of oxygen and neurine. I have 
no doubt, in my own mind, as to the power of the pnuemo- 
gastric and the sympathetic to modify, and, to a certain extent, 
co-ordinate the movements of the several parts of the heart. I 
am not at all surprised, then, to find that, when the organic and 
intellectual perceptivity of the woman are brought to feel the 
impressions made by an inflammation, whether metritis or metro- 
peritonitis, the reflex power of the nervous centres directed upon 
the heart, should rapidly and greatly augment its rate of action. 
A thought, a sentiment, a shock, can set the heart off at full 
speed. The profound impression of a great viscus in danger, 
can equally excite its forces. 

The heart, then, in puerperal fever, beats with redoubled fre- 
quency, and we expect to find the pulses at the wrist rise to 120, 
or even 150 beats per minute. 

Along with this great acceleration of the circulation, there will 
be a coincident great extrication of animal heat, and a coincident 
mischief to the constitution of the blood, whose normal rate of 
movement is expressed by a radial pulse of a certain volume, 
beating only seventy times a minute. See what great disorders are 
introduced into the actions of the economy — -see what you ought 
to do for your patient ! You ought to keep down the frequency 
of the pulse, in order to lessen the call on the sources of the 
heart's motion at the origin of the vagus, and in the sympathetic 
arches. You ought to lessen the evolution of animal heat, by 
lessening the intensity of the respiration and circulation. In 
short, you should look on all the phenomena exhibited by the 



PUERPERAL FEVER. 605 

constitution as the signs and results of a topical lesion — videl. 
the metritic, or the metro-peritonitic lesion — and you should use 
all the means within your competency to guard the constitution 
against the irritating and disordering influences of that metritis, 
phlebitis, or peritonitis. I am far from denying that a status of 
the constitution, a status, ante febrem, may rule and modify the 
march of the malady ; it would be as unreasonable to deny it, as 
it would be to deny that one individual is weak, and another 
strong — one prone to violent, and another to mere passive or 
ataxic forms of disease. But I contend that the disease is one 
and the same, everywhere, always; sporadic or endemial ; in pri- 
vate practice, or in the hospital clinic. It is essentially inflam- 
mation, and though not always to be approached by the same 
precise remedies, yet always on the same principles. 

As to the mode of treatment for our disease, it is clear that 
your intentions of cure must flow out of your views of the whole of 
the phenomena, seen in the light in which they may be presented 
to your minds at the bed side. If you imbibe the idea that they de- 
pend upon a typhous attitude of the constitution, you will scarcely 
fail to treat it as typhus. M. Tonnelle remarks upon the fact 
that almost every observer selects and advocates a method; one 
of his own, to the exclusion of all others ; one proclaiming the 
success of general bleeding — another of topical blood-letting; 
one of mercurials, and another of ipecacuanha, or of purgatives. 
It seems to me that all this uncertainty arises from the imperfect 
etiology of the case as deemed of by the proneurs of each particular 
practical mode. 

I have myself been condemned in some of the foreign journals 
as extremely sanguinary, as it is called, in my sentiments as to the 
treatment of the cases; and if by sanguinary is meant, that I look 
upon venesection as the remedy, I am willing so to be held. But 
let us proceed now, my friends, to inquire calmly and dispas- 
sionately, if we can, into the claims of the different methods of 
cure. Let us try to divest ourselves of all feelings like party 
feelings in the case, and investigate the subject with a heart-felt 
desire to discover the truth, that we may enjoy the benefits of the 
truth in going about doing good in our vocation. For my own 
part, I hope that there is in me no wish to cause any particular 
theory to flourish, since, whether it flourish or fall, I am not inte- 
rested, as I am no founder of systems, but rather a mere humble 



606 PUERPERAL FEVER. 

imitator and grateful admirer of those good writers who have 
taught me my art, and to whom I, like you, am but a Pupil and 
Student of Medicine. 

In a former part of this letter, I said that I considered Alex- 
ander Gordon, of Aberdeen, as the real reformer of our therapy in 
child-bed fever; let us now inquire further as to his claims to be 
considered so. 

If I should retrace the history of our disease, I should write a 
whole volume, and not a letter. I cannot, therefore, entertain 
you with a retrospective review of child-bed fever. 

It is enough to know that it was, before Gordon's time, exces- 
sively mortal — and is so still, where his book is not read or felt. 
Dr. William Hunter lost thirty-one out of thirty-two cases of it. 
In Paris there was an epidemic, in 1750, which killed every 
patient. Denman, Leake, and others, were afraid to treat it as 
it required to be treated; and Gordon, a man of sense, says that 
the " disease, when left to nature or improperly treated, generally 
proves fatal." 

I have already said, that Gordon lost nineteen out of thirty- 
eight of the first cases that he encountered in his epidemic. It 
was the thirty- eighth case that afforded him the materials for dis- 
section, and he makes, at the end of the account of the case, the 
following remarks, after having given a statement of the inflam- 
matory results disclosed in the autopsy. "If," says he, "either 
the quantity of the blood taken away at the two bleedings, had 
been taken away at the first bleeding, or the purging been con- 
tinued, which was exchanged for sweating, I am thoroughly con- 
vinced that we should have been able completely to overcome 
the disease. This was the opinion which I formed from the dis- 
section, and its truth was confirmed by my success in all the 
succeeding cases to which I was called. Thus the loss of this 
patient, was the means of saving many others." He subse- 
quently attended thirty-nine cases of the disease, of which he 
lost only ten, and saved twenty-nine; so that, of his whole epi- 
demic, forty-nine patients recovered and twenty-eight died. 

Dr. Gordon, at page 47, says : " Of those of these patients 
who got wine and cordials, under the idea that the disease was 
putrid, none recovered," which he considered as evidence that 
the puerperal fever is an inflammation. He admits that it fre- 
quently puts on a putrid appearance in its progress, which he 



PUERPERAL FEVER. 607 

most judiciously explains as the effect of the uncured, violent in- 
flammation; and he asserts, that when the disease is properly 
treated at the commencement of the inflammatory stage, no symp- 
toms of putridity appear. 

I shall omit any notice of the intervening chapters, and refer you 
to his sixth chapter, on the cure of the malady. At the 55th page, 
you will find these words: "When I took away only ten or twelve 
ounces of blood from my patient, she always died ; but when 
I had courage to take away twenty or twenty-four ounces at one 
bleeding, in the beginning of the disease, she never failed to re- 
cover." He insists upon it, that the practitioner should never 
take away less than twenty or twenty-four ounces at one bleeding ; 
and that, otherwise, he will fail in curing the patient. At page 56 
it appears he had felt the prejudice against bleeding in full force, 
for he lost every patient from whom he took not more than twelve, 
fourteen, or even sixteen ounces. Please to understand that Dr. 
Gordon says, " This abstraction of blood must be made within six 
or eight hours after the attack, or it will fail;" and adds that he 
declined using the lancet at a later period, because he knew that it 
would fail, and he would not bring the remedy into discredit. 

Let me cite for you from the 60th page ; which contains the 
summary of his precepts as to venesection, and although the period 
at which he would still bleed, is fixed rather later after the attack, 
I am disposed to take it as the last complete result of all his ex- 
perience. It is as follows: 

"After much experience in the disease, and after mature de- 
liberation concerning the conduct which ought to be pursued in 
any peculiar situation, I came to the following resolution: If 
called to a case within twelve hours after the attack, I insisted 
on bleeding the patient, and promised for its success ; but, if at 
a later period, viz., from twelve to twenty-four hours after the 
attack, in this case, like Sydenham with the same remedy in 
small-pox, I thought it incumbent on me to propose it as the only 
effectual remedy; but I neither insisted upon it, nor promised for 
its success." 

Mr. William Hey, practitioner at Leeds, who was a man of talent 
and candor, encountered puerperal fever in 1809-1*2, gives us 
the account of thirty of his cases. The disease was first seen by 
him December 9th, 1809, and, up to the time of his ninth case, 
in June 1810, Mr. Hey had not seen Gordon's treatise. His 



608 



PUERPERAL FEVER. 



attention now being called to Gordon's doctrines, he adopted the 
author's recommendations, and went through the remainder of the 
epidemic with the most brilliant and happy success. You will 
find the same true of Dr. Armstrong's practice in the Sunderland 
epidemic, and of the fine practice of Robert Lee of London. 

Hey does not inform us how many cases he had during the 
whole prevalence of the epidemic. He merely says, a great num- 
ber of them came under his observation. Of the thirty cases pub- 



lished in detail, the following is a tabular ■< 
treatment by venesection, or otherwise, and 
Case 1, 1819, December 9, No vs. 



2, 


a 


no date, 


3, 


a 


December 27 


4, 


a 


no date, 


5, 


1810 


, January 20, 


6, 


a 


26, 


1, 


a 


February, 5, 


8, 


a 


7, 


9, 


a 


June 18, 


10, 


a 


July 9, 



iew of the dates, the 
he results. 

died. 



recovered, 
died, 
cured. 

Here, then, is a table showing, that of ten cases from December 
9, 1809, to July 19, 1810, in which two recovered, and eight 
died, only the last, or No. 10, was really bled; since the other, No. 
9, was bled but seven ounces twice, and three ounces at other 
times, which had no effect on the disease. 

Mr. Hey having fearfully and timidly bled his patient No. 9, 
and having at that time, January 18th, six months after the break- 
ing out of the disease, become acquainted with Gordon's writ- 
ings, followed his rule in case ten, which was promptly cured — 
and which gave a fortunate turn to the direction of his views. — 
After stating the first acquaintance he got with Gordon's work, 
which opened his eyes to the truth, (see page 107, op. citat.,) he 
uses these words at page 111. "The next case that occurred 
was the first of three, which were all that proved unsuccessful in 
my practice, out of a great number, — after the change of treat- 
ment adopted in the preceding case, (No. 10,) and I hope we 
shall be able to show that the method of cure we now employ, had 
not a fair trial in any of them ; and consequently, that they can- 
not be justly considered as instances of its failure." It is to be 
regretted that we do not know how many cases he had subse- 



PUERPERAL FEVER. 609 

quent to July 30, 1810; — he says, " a great number ;" and you 
perceive, by his own showing, that the first examples under his 
care were very fatal, being eight out of ten. 

There is an admirable paper, entitled Reflexions et Observations 
sur Pemploi des Saignees et des Purgatifs, dans le Traitement de 
la Peritonite Puerperale, by Legouais. 

Dr. Legouais was resident physician at the Maternite, at Paris, 
where he had large opportunities of studying the malady in ques- 
tion. At page 21, he insists, like Gordon, upon one of the conditions 
of success in the use of blood-letting, which is, that the evacuation 
must be effectual — in an abundance suitable to the gravity and 
extent of the .inflammation. "Experience," he says, at page 
22, " has confirmed me in the belief, that blood-letting is never 
truly useful, except when it is able to destroy the malady at a 
blow, and blot it out — so to speak — at its very origin." It ap- 
peared to him that this is the very case to apply the " jugulare 
febrim," so celebrated as a mot of Galen. He says that it is 
like the fabled Hydra, which cannot be conquered but by cut- 
ting off all the heads at one blow; if a single one be left, it has 
sufficient vital force speedily to reproduce the monster, in a form 
more terrible than before. 

But I am in danger of making out of this single letter, a whole 
book, and perhaps of expressing myself with the warmth of a parti* 
san, which I sincerely desire to avoid. I ought, therefore, to make 
no more citations ; not even from the prize essay of the younger 
Baudelocque, in favor of the use of the lancet in the treatment of 
our malady ; nor from Mackintosh ; — nor from West ; — nor from 
David D. Davis ; — nor from Denman himself, after he had re- 
covered his senses upon the subject. But you must excuse me 
if I advert to the reports of cases under that distinguished author, 
Dr. Robert Collins, of Dublin. I should think that no work upon 
midwifery, that has appeared since the beginning of the present 
century, has acquired greater reputation for its author than the 
"Practical Treatise on Midwifery '," &c, by Dr. Robert Collins. 
It is certainly one of the most important contributions that has 
been recently made to the Obstetric art and science; and it 
contains the statistical results, most ably set forth, of 16,414 
births, under his direction, at the great Lying-in hospital of the 
Irish metropolis. 

I am sure, gentlemen, that no person interested in the advance- 
39 



610 PUERPERAL FEVER. 

ment of our particular department of Medicine and Surgery, who 
reads that book, can fail to acknowledge its very great merit. I 
feel, nevertheless, that I have a just right to examine, and even 
disapprove, of certain parts of the treatise — not without the pro- 
foundest sense of my obligations to the author for much most use- 
ful information he has communicated. 

If you will turn to Dr. Collins, (page 396,) you will find the 
following : 

" The result of my observations upon the treatment of puerpe- 
ral fever, is, that general bleeding, except where there is a strong, 
full pulse, and the symptoms are of a highly inflammatory cha- 
racter, is injurious," &c. — The author prefers leeching, followed 
by the warm bath, stuping, calomel and ipecacuanha with opium, 
mercurial frictions, &c. 

Dr. Collins asserts, very broadly, that his experience teaches 
him the above rule, or principles of action. 

I beg you, however, to observe how this opinion is founded. 

There occurred, under his administration of the house, eighty- 
eight cases; of which fifty-six died, and thirty-two recovered. 
" In fifteen only of the eighty-eight, did we deem it advisable to 
bleed generally ; seven of the fifteen recovered." In the whole 
of the epidemic, therefore, fifteen were bled, and seventy-three were 
not bled. Fifty-six died — of whom only eight were bled, and 
forty-eight that were not bled. Does not the question here arise : 
Why did forty-eight persons die who were not bled, while only eight 
perished that had been subjected to the treatment of Gordon? Is 
the inference a just one, that the eight died because they were 
bled, while forty-eight died because they were not bled? 

If you will read Dr. Collins' article, you will find that he leeched 
his patients very freely, and thus bled them from the skin, while 
he did not approve of the loss of blood from a large vein. 

It appears to me, that this simple statement ought to suffice to 
show you that Dr. Collins' objections to the use of the lancet are 
of less moment than they would seem to be upon a simple reference 
to his broad assertion of its inapplicability, and to his acknow- 
ledged reputation ; since it appears that his experiment of the 
venesection was inconclusive from being early discontinued. 

Dr. Robert Lee, in his " Lectures," &c, before cited, gives, 
at p. 457, et seq., a tabular statement of 160 cases of severe in- 
flammation of the uterus and its appendages, which occurred to 



PUERPERAL FEVER. 611 

him in London, from 1827 to the end of April, 1838. The table 
is presented in five columns — of which the first one contains the 
number of the case ; the second, names, residence and delivery; 
third, date of attack, and symptoms; the fourth, treatment; the 
fifth, result, and morbid appearances. This constitutes one of 
the most complete and accurate tables I have seen, and offers a 
good conspectus of the cases and modes of treatment. I have 
carefully analyzed Dr. Lee's table for you, and have divided it 
into 

1st, Those who were bled and who died, &c. 

72 w T ho were bled; recovered. 

34 who were bled ; died. 

34 who were not bled ; died. 

15 who were not bled ; recovered. 
5 no account of treatment. 



160 cases. 

Tw T o-thirds, or 106 of Dr. Lee's cases w r ere treated by venesec- 
tion, of which 72 recovered and 34 died; whereas 49 of the cases 
were treated without the lancet, of which 34 died, and 15 were 
cured : a difference in result from those obtained by Dr. Collins', 
that is very striking; 87 of Dr. Lee's people having been cured, 
while 68 died, under a bold and daring use of the lancet — where- 
as Dr. Collins lost 56 out of 88 cases in which he used the lancet 
very sparingly, and not at all according to Gordon's precepts. 

But a truce to statistics, which ought never to be the physician's 
guide. I am no admirer of medical statistics, as I have already 
stated in an early letter. I would, however, cite the above to show 
you that Gordon's precept does not kill. 

You will, by this time, perceive that I am an advocate for the use 
of the lancet in puerperal fever: my clinical experience concurs 
with my pathological views to render me so. I have not been de- 
terred by the reports of typhous forms of the malady, from viewing 
it as inflammation. Professor Moreau, who kindly showed me the 
whole interior of the Maternite, at Paris, in 1845, pointed out, on 
the occasion of my visit to that great hospital, several cases 
then under treatment. He was of opinion that in many cases 
venesection is the remedy, but, that seasons occur wherein the 
patient will not tolerate the loss of blood. M. Cazeaux, who was 
on duty at the Clinique d' Accouchement, gave me the same opinion ; 



612 PUERPERAL FEVER. 

as did also Professor Retzius, of Copenhagen, whom I had the 
pleasure to see there while visiting M. Cazeaux's wards. All 
that I saw on those occasions, and all that I have myself witnessed 
before and since, confirm me in my admiration of Dr. Gordon's 
precepts; and I adhere to, and adopt, and desire, as your Professor 
of Midwifery, to lead you also to adopt, Dr. Gordon's views. 

Do you ask me if I expect to cure my patients by venesection, 
and do they never die under the treatment ? I answer, that the ma- 
lady is able, in many cases, to resist all sublunary power ; and that 
numerous instances must continue to occur in which the curable 
stages are overpassed before any manifestation of the disease can 
be discovered. But, where the disease is curable, it is more cura- 
ble by the lancet than all other means besides; and that patient is 
exposed to unnecessary and dangerous risks, whose life is confided 
to any other single anchor of hope and safety. I look upon it as 
child's-play, to attempt the cure of these great inflammations by 
doses of ipecacuanha — by calomel — by cathartics — by opium — 
by turpentine. I think that even the miserable far niente of the 
Homceopathist is likely to cure the cases that are curable with- 
out the lancet — and that his nichts thun will allow a patient to 
get well whose constitutional force is equal to the overcoming, by 
resolution, of a metritic or peritoneal inflammation. 

What can calomel do in one of these great cases of peritonitis ? 
Let me show you how inadequate is the remedy. See, now! 
The alimentary canal is not less than forty feet in length from 
the cardia to the rectum. If divided with the enterotome, and 
laid out on its mucous surface, it would average a breadth of four 
inches by a length of forty feet. If you reduce this into square 
feet, you have sixteen square feet of peritoneal surface, even leav- 
ing out of the computation the rest of the serous membrane of the 
abdominal cavity. 

I entertain no doubt of having seen many individuals, in whom 
the wiiole of this vast superficies w T as in a state of inflammation. 
But the pain of a panaris, or the irritation of four or five square 
inches of erysipelas, will often suffice to disorder the whole con- 
stitution. What shall we think, then, of the disturbing power of 
an universal peritonitis in a woman just out of her gestation, and 
just escaped from the pains of her travail? And for such a case as 
this you propose to put — what? — what is it you are going to do 
with such a solemn air? You are going to put two, or ten, or 



PUERPERAL FEVER. 613 

twelve grains of calomel upon the mucous membrane of the sto- 
mach, to cure sixteen square feet of red-hot serous tissue! Does 
it not seem preposterous? 

Read Gordon. Learn to make your diagnostic of child-bed 
fever; and then freeing your spirit from the shackles of the 
schools, learn to act upon the promptings of your reason and 
judgment. Do not suffer yourself to be governed by a symptom. 
Be governed, rather, by a clear, dispassionate, perspicuous obser- 
vation of the state of the whole creature, and her wants. Be- 
lieve me, my dear friends, that there are many cases of grave 
constitutional disorders, in which the pulse is no guide to the 
physician; and that if you be but pulse-feelers, and nothing else, 
as long as you live, you will barely rise above the height of the 
Chinese doctor, who founds his diagnosis, prognosis and thera- 
peutical course, upon a judgment of the pulse of a lady, which is 
thrust through a hole in the door for his opinion as to her health 
and requirements. 

I am very sure I have been many times Me,jugulare febrim, 
in puerperal fever, by a Gordon venesection, that I should not 
have dared to make had I been led only by my fingers. Are 
not a man's senses more than one? and shall one sense carry all 
the others away captive, and bind in chains the contrary judg- 
ments arising out of their perceptions? 

In these great circumstances, neither you nor any man should 
trust for his guidance to the radial pulse alone. You should ex- 
amine the brachial, the carotid, the temporal arteries, and know 
them all. You should go to the fountain head of the circulation, 
and by a careful, prolonged auscultation of the heart, confirm or 
correct the more imperfect notions of the state of the sanguiferous 
system derivable from touching the radial pulse alone. 

I repeat it — read Gordon; learn how many hours are fled ; and 
judge, whether the progress of the malady may have carried the 
victim beyond the curable stage ; for there is, there must be, a cura- 
ble stage! Is the woman past hope before her sickness is begun: 
Is she foreordained to death? 

Having now laid before you, perhaps at too great length, my 
opinion of the indispensable necessity for venesection in our ma- 
lady ; its safety, and its superiority over all other means, I need not 
say anything further on the subject, except to warn you not to trust 
this operation to other hands than your own. You should always 
be present; the light should be good, in order that you may 



614 PUERPERAL FEVER. 

clearly observe the changes in physiognomical expression that 
attend the flowing from the vein. The apartment should be in 
order; no noise, no movement, ought to be allowed. The patient's 
position should be carefully directed ; neither allowing her to be 
raised too much, nor to be on pillows too low. A man who is about 
to bleed in a puerperal fever, should be solemnized : there should 
be a mit l)iiife (gkittes sentiment about him ; for, on his operation 
hangs a human life. Death, widowhood, orphanage, are often the 
questions that are suspended upon this eventful ministry. 

Many doctors prefer leeches in the treatment. — You may see 
what a very free use of them was made by Dr. Collins — and you 
may see, also, that the success could not have been much more 
unsatisfactory. Lee is no leecher ; he is a good Gordonian bleeder 
in our case, and owes his brilliant success to that. Desormeaux 
was a leecher and a mercurializer. You will find it so if you will 
read Tonnelle, who tells you he lost 240 patients with it at the 
Maternite. Chaussier was a good bleeder ; see what his intelli- 
gent eleve Legouais says about it. 

I never could well understand the motives of those, who, though 
they are more frightened at the click of a spring-lancet than "a 
hurt fowl or a struck wild duck" is at the report of a caliver, yet 
find nothing at all distressing in the noiseless absorptions of two 
or three hundred leeches. They dread Dr. Gordon's direction to 
take twenty ounces at a bleeding, but they are not in the least 
alarmed at the abstraction of forty or fifty ounces by 300 leeches; 
not put on all at once, it is true, but in the course of a very few 
days. 

For my part, I am afraid of leechings. — I am not afraid to bleed 
with my lancet, with a good light on the patient's face, and my 
fingers on the pulse ; for I can always feel satisfied that the flow 
is enough — not too little, and not too much. I can stop the jet 
with the dossil of lint — I can interrupt, or arrest, or recommence 
the bleeding in an instant; — I can auscult the heart while it goes 
on, and feel that I am guiding a powerful, but docile servant of 
my ministry. In leeching, I always procure fatigue, pain, damp, 
and often, exhaustion, for my patient. 

In puerperal fever the inflammation is on the intestinal perito- 
neum. All the blood of the inflammation is blood from the digest- 
ive arteries — the celiac, and the two mesenteries. — What reason 
have I to expect to control the action of their distal and capillary 



PUERPERAL FEVER. 615 

branches by leeches placed on the skin of the abdomen ? Would it 
not be as reasonable to leech the calf of the leg, as to leech the 
belly, for the cure of child-bed inflammation ? I shall not deny that 
I have, on occasions, applied leeches to the abdomen; but I have 
ever done so in doubt, and shall, probably, continue so to use 
them even less frequently than heretofore. 

Great stress is laid upon the power of calomel to cure the dis- 
ease, and many physicians regard it as the sheet-anchor of hope 
and safety. I have no doubt that its aplastic therapeutical force 
is great, especially when given in large doses, and when its 
cathartic influence is lessened by combination with opium. A 
woman who has been attacked, and who has been bled, ought to 
take some ten grains of calomel with a grain of opium: a dose 
that should be repeated in the course of some four or six hours, 
provided the first one be not followed by alvine dejections. 

A dose of the mild chloride of mercury almost invariably pro- 
duces a sensible degree of qualm, or nausea, which has a check- 
ing influence on the intenseness of the circulation ; thereby 
moderating the threshing power of the heart and the vessels so 
much, that it hinders the increase of the fibrinous element in the 
blood. — Remember, that the fibrinous element is expressed by 
3*5 ; calomel assists to prevent its figure from going up to fifteen, 
or even twenty. 

Calomel excites the secretory offices within the alimentary 
tube. As a general rule, the more abundant those secretions, the 
more completely are the remote branches of the digestive arteries 
disengorged. All those branches furnish secretions for the bowels, 
or for the liver ; they go nowhere else. — Calomel, then, is a good 
and reasonable, nay, a precious drug for the occasion. But to 
trust to it alone, is to lean on a broken reed that pierces the hand. 
Calomel is one of the leading juvantia in the cure, and nothing 
more. 

So rapid is the rush of the attack and conquest, that " cita 
mors venit, aut Iceta victoria" as Gordon quotes the lines from 
Horace. It is not a case in which a prudent man dare wait for 
the alterative influences of a mercurial ptyalism. If those in- 
fluences could be set up in time, they would often prove the 
effectual bar against the destructive advance or continuance of the 
malady. 

Many a life may be saved, in the course of a long medical career, 



616 PUERPERAL FEVER. 

by means of the supporting consolations, and the recovering ex- 
hortations, that fall from the lips of a medical man, who is known 
to be worthy of confidence and trust. I hope that you will not 
believe, because you have got your Diploma in your hand, and 
because you have just been told in the College, the names and the 
doses of the various articles of the Materia Medica, that all you 
have to do in this world, in your vocation, consists in meting 
out those drugs and medicines. I hope you will live long enough 
to know, that the function of the physician goes far beyond the 
exhibition of his doses, and that the pow T er of his presence, of his 
deportment, of his opinion, and his decision, is a real power over 
the mind and the body of the patient, more true, and more useful, 
than the pretended Mesmeric force. An eloquent man can control 
the wildest mob, or sway the opinion of the gravest senators. 
Eloquence, however, is not found only in the harangue; you may 
see it in the gesture; it is heard in the whisper; its most potent 
spell often breathes in that still small voice, in which, amidst terror 
and doubt and anxiety, he gives assurance of protection and 
restoration. 

In the conduct of cases of puerperal fever, it will be a matter of 
no inconsiderable moment to determine the precise seat and degree 
of the lesion ; and for this purpose, it is not sufficient for you to go 
into the patient's apartment and ask half a dozen questions as to 
the state of the bowels— feel the pulse, and ascertain the state of 
the tongue. You should examine your patient carefully. If she, 
for instance, lie in bed covered up with two blankets and a coun- 
terpane, it won't do for you to examine the state of her abdomen 
through the bed-clothes, petticoats and all, as I have seen people 
do. Her life is at stake, and it will be lost if you do not under- 
stand how it is at stake, and how to save it. She should be 
visited often, — many times a day. A careful note should be 
taken of the state of her pulse ; you should set down, on a sheet of 
paper, the state of her respirations, and insert memoranda of all 
the great points of her case — the doses of medicine, and the sen- 
sible effects produced by them. 

Remember, that when you feel the pulse, you do so for the pur- 
pose of knowing what her heart is doing, which you will not ahvays 
be able to ascertain by touching the pulse alone; therefore, when- 
ever you pay a visit, examine the heart carefully ; note the im- 
pulse, the force, the area, and by comparing the impressions 



PUERPERAL FEVER. 617 

made upon your mind, communicated through your fingers, by the 
radial artery, with those conveyed by the heart itself, through the 
ear, endeavor to get a true and correct notion as to the general 
momentum and effect of the arterial circulation. The arterial 
system develops in the brain, in the whole nervous system, the 
flash of life ; where it is greater, the life is greater; where it is less, 
the life is less. Nearly the w T hole of your powers to modify the 
rate of life, are powers exercised upon this very force of the circu- 
lation ; and the physician never knows so perfectly the state of the 
life force in his patient, as when he gathers that knowledge from 
a perfect knowledge of the state of the circulation of the blood. 
Study the pulse, and let it be a constant study; it has been ad- 
mitted of all times, that a good pulse-feeler is quoad hoc, a good 
physician, and that it is one of the greatest accomplishments of 
the medical station to know the pulse well; and why? Because, 
a knowledge of the state of the pulse reveals the state of the life 
forces. To know the pulse, may almost be said to constitute the 
(E&rmibkraft of the medical ability. But, take heed that you be 
not pulse-feelers only. 

You will suppose that your patient is doing well, if she has 
moderate perspiration, occupying the whole superficies of the 
body; and particularly, if the perspiration have an unctuous feel. 
A very thin and watery perspiration is not so favorable ; for, when 
it is unctuous, it shows, not only that the pores are free, but that 
the follicles are in a state of activity. 

Your patient will be better, if the pulse is becoming less fre- 
quent, and at the same time losing its volume, after having been 
too large ; or if it is recovering its volume, and becoming less fre- 
quent, after having been too small. Your patient is not better, if 
the pulse becomes more and more frequent; for its increasing fre- 
quency indicates an increased distress of the whole constitution. 

If her respiration become slower, deep, and long, more equable, 
she will be better; if it be saccadee, jerking, requiring the aid of 
the accessory muscles, the sign is almost to be held fatal. 

If the urine is abundant, the sign is good. 

If the tympanitic distension of the bowels is growing less, giv- 
ing to the muscles of the belly, relaxed after parturition, their 
usual soft, fluctuating feel, instead of the hard, elastic and swollen 
appearance which they before presented, it is favorable. If the 
abdomen become more and more distended, hard, intolerant of 



618 PUERPERAL FEVER. 

contact, the sign is bad. Nobody is better in a fever, in whom 
the hypochondria are tumid. Here is one of the aphorisms of Hip- 
pocrates: "Febricitantibus, quibus hypochondriac tument ma- 
lum." Here is another: " Febricitantibus, quibus hypochondriac 
non tument bonum." This aphorism was written four hundred 
years before the advent of the Saviour ; it expressed the truth then, 
ever since, and now. 

If the thirst diminish, it is good; if it become more and more 
insatiable, the sign is unfavorable. If the sensibility of the abdo- 
men, as tested by pressure, grows gradually, and not suddenly, 
less, the sign is good. But if the patient, having been extremely 
sore, ceases suddenly to complain, it is probable that she is nigh 
unto death; for, the cessation of the pain depends upon the sud- 
den cessation of the disease. The disease was inflammation, 
and the inflammation having rapidly come to its last term by 
effusion, a copious effusion of lymph and serum and albumen 
into the belly, has cured the disease — and the patient is about to 
die ; just as the tension of the vessels of the brain, which gives the 
most intense pain, is relieved by the extravasation of the blood, 
which converts the headache into a fatal apoplexy. The people 
will say that mortification has taken place. Why, a woman won't 
live in this malady until mortification takes place ; she has not 
time for mortification to take place ; therefore, in your autopsy, you 
will not find mortification. 

In order to show you your prognostication upon the sudden ces- 
sation of pain in puerperal fever, I am going to quote a case for 
you, which is enough to make one feel something like awe in the 
reading of it. It is the first case related by Gordon, that of Andrew 
Low's wife — No. 15 in his table. It is at the 37th page of Bar- 
rington & Haswell's edition. 

"Case I. John Low^s wife, No. 15 in the Table. — In the af- 
ternoon of the 19th of August, 1790, John Low, miller at Justice- 
mills, came to my house, requesting me to go immediately to his 
wife, 'who,' he said, 'had swooned after delivery, and was in 
great danger.' I accordingly went, and found her in a dangerous 
situation ; she complained of an acute pain in the lower part of 
the abdomen, attended with a very great degree of fever, the ve- 
locity of the pulse being at the rate of 140 strokes in a minute. 

"The disorder commenced with a violent rigor at six o'clock 
in the morning, being about 36 hours after delivery. 



PUERPERAL FEVER. 619 

"I had ho difficulty in ascertaining the patient's disorder, hav- 
ing had previous opportunities of seeing it both in London and in 
the course of my practice in Aberdeen, for this was the fifteenth 
case I had attended since the epidemic began, though the first of 
which I kept a journal. And, in every respect, the disease an- 
swered the description of that known to practitioners by the ap- 
pellation of the puerperal fever, a distemper which so frequently 
proves fatal to women in child-bed, baffling the skill of the most 
eminent physicians. As, therefore, I had so often seen the dis- 
ease, I could not be puzzled in regard to the proper method of 
treatment; though, at the same time, I was well aware that I 
could by no means promise success. 

"I accordingly ordered bleeding to the quantity of sixteen 
ounces, the abdomen to be fomented, and a glyster to be given; 
and, at the same time, I ordered large quantities of diluting drink. 
I likewise directed an anodyne diaphoretic draught to be given at 
night, and a cooling laxative the ensuing morning. 

"On the 20th, when I visited the patient, I found the velocity 
of the pulse somewhat diminished, but no abatement of the other 
symptoms (the pain and tension of the abdomen remaining as 
before). 

"The laxative given in the morning had the desired effect ; the 
blood drawn exhibited a very thick inflammatory crust ; the lochia 
were suppressed ; the urine was scanty, and voided with pain ; 
when recent, it was high colored, but when allowed to stand for a 
short time, it became exceedingly turbid. 

" The fomentations were continued, and an opiate given in the 
evening. 

"On the 21st, when I visited her in the morning, I was happy 
to find that she had been pretty easy throughout the night, and 
had enjoyed some hours' sleep. The pulse was 136. She was in 
a profuse sweat, which, I hoped, would prove critical, and, there- 
fore, endeavored to promote it by small doses of tartar emetic 
in the saline mixture. But I was sorry to find that I was disap- 
pointed in my expectation ; for, when I returned in the afternoon, 
I found that the sweat had disappeared, being succeeded by a 
diarrhoea. 

"The patient now complained of very great pain, and the 
swelling of the abdomen seemed to increase. I ordered an opiate 
in a large dose, and applied a blister to the abdomen. 



620 PUERPERAL FEVER. 

" On the 22d, I was sorry to find that the disease was making 
rapid progress, in spite of all the remedies employed ; and, as I 
perceived that the diarrhoea was not proving critical, (for the pain 
and tension were extended over the whole of the abdomen,) and 
that the patient's strength was sinking, all hopes of recovery 
were now totally abandoned. 

"The patient's agony was now extremely great, and called 
loudly for relief; I therefore thought proper to administer opium 
both externally and internally, on purpose to mitigate pain, and, 
if possible, to procure rest. 

"I went early in the morning of the 23d, to visit my distressed 
patient, and found that the storm was lulled into a calm. The 
friends received me with transports of joy, vainly thinking that 
the danger was over. 

"The patient, supposing herself perfectly well, asked my per- 
mission to rise; for she seemed to feel no pain, and suffered me 
to touch and press the abdomen, without showing any signs of 
uneasiness ; a proof that the parts were in a state of gangrene : 
for this sudden cessation of pain in the puerperal fever, is a fatal 
symptom, which announces the approach of death, and denotes 
that a mortification has taken place. The friends, ignorant of 
this circumstance, were quite overjoyed to see the patient so com- 
posed, after such excruciating pain. However, notwithstanding 
this composure and apparent ease, it was evident, from the 
ghastly appearance of the countenance, from the tumefaction of 
the abdomen with the absence of pain, from the sunk state of her 
pulse, and from the coldness of the extremities, that death was 
not far off. Accordingly, in a few hours, the scene was closed." 
Can one imagine a more distressing scene than this ? How per- 
fectly, how naturally, he paints it. I have looked upon such as 
it many times. It goes to the heart. 

You will see that Gordon speaks of diarrhoea. I have not very 
often seen diarrhoea in patients affected with puerperal fever. I 
have met with it occasionally, however, and have been surprised 
to discover the power of the bowels to transmit liquids — for these 
stools are always fluid ones; while several cubic feet of gases, 
constantly in the alimentary tube, w T ere obstinately retained 
there, keeping up the enormous distension, and rendering the 
cure hopeless as long' as it continued. If, when a patient has 
had a diarrhoea, it gives place to a more healthy character of the 



PUERPERAL FEVER. 621 

alvine dejections, and disappearance of the tympany, the sign 
will be good; but an increase in the frequency of the alvine dejec- 
tions, and, above all, their occurrence without the patient's con- 
sciousness of the circumstance being excited, are signs the most 
disastrous; particularly where the belly remains much distended. 

When a patient is going to die of this malady, it happens, some 
time before the fatal event — some hours, or a day, or even two 
days beforehand — that she begins to have eructations. If these 
eructations are accompanied with a sound like hiccough — if they 
are singultiform, you need scarcely entertain the hope to rescue 
the patient from an impending fate. The eructations become 
more and more frequent; the fluid discharged may be at first 
whitish; it acquires at length a greenish tint, and everybody 
supposes she is bringing up bile ; it comes at length to be a slight 
vomiting; she brings up a spoonful at a time — a wineglassful, a 
teacup full: it becomes again brown, and looks like fine coffee- 
grounds; it becomes perfectly black — it is black- vomit. It is 
the black-vomit that accompanies the fatal serous inflammations 
of the abdomen: you will find it in almost all persons perishing 
from intussusception, from strangulated hernia, and various forms 
of enteritis. I have no doubt that when it begins, the serous coat of 
the stomach has begun to be inflamed ; and that the inflammation, 
increasing in intensity, coincides with the change of color, and 
quantities, of this ejected fluid. So that, at the last, that is to say, 
when she is bringing up half a basinful at a time of this vomito, 
her stomach is already half dead. 

How painful it is to a physician, to stand by at the commence- 
ment of these vomitings, and to look through the dark vista along 
which the patient is seen by him to move; while the friends and 
acquaintances are filled with the cheering hopes of health speedily 
to be restored. Mrs. Low's friends received Gordon with "trans- 
ports of joy." 

If she has had an abundant secretion of milk, the secretion 
will be suppressed if she be violently ill with puerperal fever; for 
the abandonment of its duty by the lactiferous gland, is a dan- 
gerous symptom, expressive of extraordinary constitutional disor- 
der. The maintenance of the power of the milk gland is always 
to be held as of good augury in the case. 

The total suppression of the lochial discharge is pernicious in 



622 PUERPERAL FEVER. 

its influence, and discouraging as a sign; the restoration of the 
discharge is hailed as a new attempt at recovery. 

And now, I have a few last words to say before I close this 
letter. You should never take your leave of a patient who has 
been confined, without giving the clearest, the most impressive, 
directions, as to circumstances that might render your recall ne- 
cessary. The majority of these diseases come on in the night time, 
and many people are unwilling to awaken the physician, or even 
to call him at a very early hour in the morning; either because 
it is inconvenient to themselves to send, or that they dislike to 
give him the trouble to pay an extra visit. They will expect him 
to look after his accouchee, and are very apt to wait until the ex- 
pected hour of his call; as to which, they may be subjected to 
disappointment, since his assistance, in person, may be required 
elsewhere, and since, having left his patient well at the last visit, 
he is apt to consider her still so upon receiving no communica- 
tions. 

You know Gordon says, that if you don't cure the puerperal 
fever within the first six or twelve hours, you have little chance 
to effect a cure, and that the nearer you are to the time of the 
attack, the greater of course will be your expectation of suc- 
cess. I think I scarcely ever leave a patient, after she is put 
to bed, without addressing myself especially to her, and explain- 
ing to her the impropriety of taking anybody's advice as to her 
case, except that of her regular medical attendant. I tell her, 
that it is even very difficult for the physician to discriminate be- 
tween the various forms of disease in their attacking stages, and 
that it is impossible for unlearned persons to do so. I endeavor to 
make her understand, that some of the forms of disease that affect 
lying-in women, that are perfectly curable if treated promptly, 
may, in the course of from six to ten hours, pass entirely beyond the 
hope of recovery ; and I say, " If you are sick during my absence, 
see to it that I be instantly notified of it. Don't consult with any- 
body as to the propriety of letting me know that you are indis- 
posed. You have placed your safety in my keeping; it will be 
the last degree of injustice to me, should you be taken sick in the 
intervals of my visits, not to inform me thereof, but instead of 
mine, to take the opinion of a nurse, or of some acquaintance. 
I charge you, therefore, that you let me know', as speedily as 
possible, if anything should happen to derange your health." 



PUERPERAL FEVER. 623 

I give similar directions to the monthly nurse, and, if I have the 
opportunity, I ask the husband of the lady to watch over her, in 
order that I might receive the earliest information of any indisposi- 
tion. This course I have pursued for years, and yet, up to this 
hour, I am unacquainted with a single household or individual in 
whom I can trust on such occasions. If the lady is taken sick, 
the nurse, or the grandmother, or she herself, will explain it as 
after-pains, or as headache, or as rheumatism ; and if the curable 
stage has been gone through before your visit, such signal diso- 
bedience of express directions, such enormous stupidity, is apt to 
be followed by the loss of the patient ; a loss so great, that there 
are no words in which I can set forth the mental distress it occa- 
sions. Please to understand, that if you scrupulously adopt the 
plan which I have above recommended, and should practice mid- 
wifery for half a century, you will scarcely find ten occasions in 
your whole life, in which a prompt information will be communi- 
cated to you ; and this it is that makes the life of an accoucheur 
more painful than that of the surgeon or the general practitioner. 

It is very singular, but it is very true, that physicians are subject 
to these constant anxieties and mortifications. A woman will send 
a break-neck message after you, to call you out in night and 
storm and tempest, because her baby has had a bellyache, or 
possibly a green stool; but she will not send for you, perhaps, if she 
is standing on the brink of the grave, as every woman is who 
is even threatened with this direful disease. She will ask the 
nurse to do something to cure her. Be not discouraged, however ; 
the fault will not be yours if you should have taken all the pre- 
cautions in your power; whereas, a heavy charge would lie upon 
your conscience, should a patient be lost in consequence of inat- 
tention, on your part, in issuing the needful directions. 

After the death of a charming lady here a few years ago, I sent 
to her husband a copy of Gordon's treatise. She fell a victim to the 
imprudence and stupidity of her nurse, who allowed her to pass 
through the curable stage of an epidemic puerperal fever, de- 
claring that it was only after-pains, which she understood as well 
as the doctor, and that she would not have the doctor sent for. 
"Haven't I nursed," said she, "for thirty years and more, and 
must I have a doctor put on me because you've got an after- 
pain? Nonsense!" And so, when her physician, who had left 
her well a few hours before, was at length requested to visit her, 



624 PUERPERAL FEVER. 

he found her far gone — past all hope of recovery. The gentle- 
man read Gordon, and when he returned me the volume, "Oh, 
sir!" said he, " why is it that this book is not to be found in 
every house? — If I had read these pages sooner, I should not, per- 
haps, now mourn over my irreparable loss." 

I could relate to you many histories, setting forth the import- 
ance of early information in this case. But it is time to close this 
letter, in which I have endeavored to give you what I regard as 
sound and wholesome views upon the subject of which it treats. 
If you will take my advice, you wull buy Barrington & Hasw T ell's 
book, and read it with the greatest care. And wdien you shall 
have read Gordon, Hey, Armstrong, and Robert Lee, if you will 
practice with ipecac, and calomel, and nothing else, I cannot be 
responsible for you, though I shall be very sorry for you. 

C. D. M. 



LETTER XLII. 

CRURAL PHLEBITIS. 

Gentlemen: — There is a disease of which I have not yet 
spoken, and which is vulgarly known by the term Milk Leg. It 
has been called by the writers, phlegmasia alba dolens puerpera- 
rum, or the painful white swelling of the lying-in woman. Some 
of the Frenchmen still call it lait repandu, which is a transla- 
tion of the English word milk leg; a word employed to express 
the sense, that the milk of the woman has fallen into her leg, and 
inflamed and swelled it; and I suppose, indeed, that in this nine- 
teenth century, half gone as it is, you will have plenty of trouble to 
convince your patients that it will not be your duty always to get 
the milk out of the leg, or so to regulate your prescriptions, as to 
provide against the effusion of more milk into the cellular tissue of 
the limb. I suppose you will laugh, gentlemen, at the idea of 
having milk in a woman's leg, for you know milk is made in the 
breast, and not in the leg ; it is pretty much like saying, that a 



CRURAL PHLEBITIS, 625 

man has a salivation of his liver, or a diarrhoea of his kidney; in 
fact, it is sheer nonsense. 

There are a great many doctors in this country — people who 
don't read books — who, while they don't suppose that it is milk 
in the leg, yet persist in believing that it is inflammation of the 
cellular tissue : though no man ever saw one suppurate, and though 
every man knows that when cellular tissue inflames, it is almost 
sure to suppurate. I should like to see a woman get well of an 
inflammation of the cellular tissue of the whole limb from the 
crista of the ilium to the os calcis, and from the pubis to the meta- 
tarsal bone of the great toe ! — one whose thigh is bigger than a 
man's body, and her leg swollen to the size of that of an elephant! 
— that is to say, get well without a suppuration, or, indeed, in any 
way. 

Some persons have supposed that the swelling is produced by 
a disease of the absorbents of the limb ; and, in fact, nothing was 
known about it, until Robert Lee, the same Robert Lee of whom I 
have spoken so many times in these letters, made the discovery of 
it, and clearly demonstrated its true pathological nature ; showing 
that the lesion in the disease, is a lesion of the veins of the limb, 
for which, he gave to it the name of Crural Phlebitis, the name by 
which it is called by all physicians who know anything about it : 
it is called milk-leg only by those who know nothing about it. 
The old doctrine of milk-leg is still taught by persons in high 
places. 

Dr. Lee, in his Essay on Crural Phlebitis, (Barrington and Has- 
well's ed., page 314,) after having given a literary history of crural 
phlebitis in puerperal women, says: "It is a remarkable circum- 
stance in the history of crural phlebitis, that nearly a century and 
a half should have elapsed, after it was first clearly pointed out 
by Mauriceau, before an opportunity was presented of ascertain- 
ing, by dissection, the precise nature of the disease. There had 
been opportunities, as I have shown, to determine the accuracy of 
the different hypotheses that had been advanced, but these were 
neglected, and the real nature of the disease, and its commence- 
ment in the uterus, were imperfectly understood, until I ascer- 
tained, by dissection, the true nature of the complaint." Dr. Lee's 
account of this dissection is in the Medico- CMrurgical Transac- 
tions, vol. xv., 1839. 

The disease under consideration, commences in the endangium 
40 



626 CRURAL PHLEBITIS. 

of the vessels; it is the same malady which most frequently 
carries off the chirurgical patient who has been subjected to am- 
putation of the limb. It is the same thing that happens to every 
blood-vessel, whether artery or vein, around which you cast a 
ligature, and tie it, for the suppression of hemorrhage. Fortu- 
nately, the application of your simple ligature develops only a 
sufficient amount of inflammation to effect the union of the dis- 
rupted endangium, and constitute a plug of lymph, fitted to be- 
come a bond of union for the opposing walls of the vessel, and thus 
restrain the hemorrhage after the ligature shall have fallen off. 

Crural phlebitis may begin before the termination of the gesta- 
tion ; I have met with several cases in which it occurred six weeks 
before the child was born. It may commence soon after the end- 
ing of the labor, or not until the woman has begun to move about 
her chamber ; she is liable to it at any period within the lying-in 
month. A man is liable to it; so is a child ; — it is by no means 
peculiar to the gentler sex. 

Many of the cases of swollen limbs, that are looked upon by 
the Doctors, as oedema, coming on at the close of great chronic 
visceral diseases of the belly, such as enormous enlargements of 
the liver, or spleen, or great heterologue glands, that are pro- 
duced there; or cancer of the stomach — many of these swellings, 
I say, are not oedema, as the Doctors suppose, but they are crural 
phlebitis. I have known them to be so at the beginning, and have 
proved them to be so after death ; for I have found the great crural 
veins and internal iliacs filled with lymph, and pus, and coagu- 
lated blood, and, in some instances, totally obstructed. Dr. Lee 
has found some puerperal cases, in which the great crural vein, 
in returning into the body, has been lost, like an African river in 
the sands; no trace of the vessels being left by the ravages of dis- 
ease, w 7 hich had extended from the endangial lining into the 
circumvolved tissues within the abdomen. 

Now, gentlemen, see a limb supplied by a great femoral artery 
and profunda, wdth its anterior and posterior tibials, and all the 
other branches: imagine these arteries healthy, strong, perfect in 
structure and volume ; and see a current of blood, driven into 
them by the contraction of the heart under the powerful excite- 
ment of a great fever; and then, imagine the femoral vein or the 
saphena, obstructed by thickening of its endangium ; by quanti- 
ties of plastic lymph which has exuded from the inner wall ; by 



CRURAL PHLEBITIS. 627 

strong, firm coagula of blood, which have been arrested on its now- 
irregular surfaces; by a quantity of serum exuded between the 
outer or fibrous coat of the vein and the cellular sheath in which 
it runs, so as to give you the feeling, when you pass your finger 
from Pouoart's ligament down the limb to where the vessel 

J. o 

pierces the triceps muscle, as if the finger were pressing upon a 
body as large as a" man's thumb, and as hard as a stick. Now, 
tell me, w r hat is to become of all the blood dashed into the limb 
by the force of an infuriated systemic ventricle; and how is it to 
get out? How is the woman to avoid the great swelling of the 
limb, which you call phlegmasia alba, or milk-leg, but wmich you 
would better call crural phlebitis? 

It is impossible to suppose such a condition of the vessels, with- 
out conformable swelling: for the vein which carries blood from 
the limb, is virtually compressed, as if you had tied it up with a 
ligature, preparatory to bleeding it. The vein is as if you had 
put the pad of Petit's tourniquet upon it, and left the artery per- 
fectly free and unobstructed. But it is not the crural vein alone 
that suffers in these cases; the inflammation not un frequently 
extends into numerous superficial branches, which become extra- 
ordinarily sensible to the touch, and hard ; evidently containing 
within their cavities, quantities of coagulated blood. 

But, the disease is called phlegmasia alba dolens. What makes 
the pain ? Don't you know that the femoral artery, the crural 
vein, and the great crural nerve, constitute a fasciculus, and they 
are bound up in a common sheath or theca, until they reach the 
point where they perforate the triceps to get into the ham ? Well, 
then, the inflammation of the endangium of the crural vessels dips 
through the fibrous coat, and causes the infiltration I spoke of in the 
common sheath of the fasciculus; producing the long, hard, cord- 
like swelling extending from Poupart's ligament even into the ham. 
The whole crural nerve is thus compressed, gentlemen ; but if you 
compress the crural nerve, w T on't the woman have pain? Won't 
she have neuralgia? Well, the sensibility that the woman has, 
and the pain that she suffers in crural phlebitis, are essentially a 
neuralgia from pressure on the crural nerve. 

The veins in the interior of the body are, for a long time, com- 
pressed by the gravid uterus; and sometimes, compressed with 
great force, which is increased enormously in the throes of labor. 
They are not only compressed, so as in some instances absolutely 






628 CRURAL PHLEBITIS. 

to suffer contusion, but the whole of the veins of the lower ex- 
tremities are, in many women, for a long time, distended by the 
pressure of the womb, causing oedema gravidarum, and that very 
common occurrence, varix gravida?. Such a constant, long-con- 
tinued pressure upon the vessels, might well be supposed to have, 
in many instances, the effect of developing an inflammatory 
state there ; this would be endangitis. But the endangitis is more 
likely to affect the veins below, than those above, the point of pres- 
sure. There are many cases in which inflammation, commencing 
in the branches of the uterine veins, and spreading along the en- 
dangium to the internal iliacs, passes out beneath Poupart's liga- 
ment, along the external iliac to the femoral, and thence to all the 
veins which become subject to it in the leg. It will be first sus- 
pected by pain felt at the groin, or in the calf of the leg. I am 
very sure, that, in many of the cases I have met with, my first detec- 
tion of the existence of the malady, was made in consequence of 
complaints as to pain in the calf of the leg. When a woman who 
has been confined, or who is pregnant, tells me she has a pain in 
the calf of her leg, I put a thumb upon the spine of the tibia, and 
the fingers upon the calf, and then suddenly compress the gastro- 
cnemii and soleus against the bone ; if the woman shrinks from 
the pressure, and makes an outcry, I next ask permission to ex- 
amine the groin ; and if I feel the swollen ridge of the theca of the 
vessels, I know that my patient labors under crural phlebitis. I 
then examine the external iliac, by putting my hand on the same 
side of the hypogaster, and pressing the teguments against the brim 
or strait of the pelvis as far as I can push them; when I am very 
sure to detect the evidence of inflammation extending up into the 
body, if it goes so far inwards. 

The calf of the leg will be found hard. Let the woman lie upon 
her back, and be directed to draw both of the knees up in the 
bed until the tibise become nearly vertical : you now take hold of 
the calf of the leg, lightly from behind, and endeavor to shake it 
from side to side. You will find you can't shake it, for the whole 
mass seems attached to the bone, or packed against it. If you 
shake the other calf, it will be perfectly flabby and movable in 
your hand; the result of this comparison will settle the diag- 
nostic. 

As you will have to treat the case, you ought to be able to 
make comparison of its progress from day to day ; to which end, 



CRURAL PHLEBITIS. 629 

take a piece of broad tape, cast it around the thickest part of the 
calf of the leg, measure it accurately, making a mark with a pen 
or pencil upon the tape, to show the exact circumference, with the 
date inscribed. Let this tape be carefully kept by the nurse for 
future reference; and let this measurement be repeated from day 
to day. 

If you detect the disease in its formative stage, or in its earlier 
stages, you will find it before there has been much swelling, par- 
ticularly of the thigh ; and you should announce that the thigh 
w T ill become enormously swollen, provided your treatment should 
not succeed in assuaging it. There will also necessarily be fever, 
or the expression of constitutional distress, from so great and so 
painful a malady. 

And now, gentlemen, as for the treatment. It is, rarely, proper 
to bleed for this disease ; because, the disease is seldom detected, 
until one of the terminations of inflammation has been reached. I 
say one of the terminations of inflammation, for the termination of 
an inflammation is reached, first, by resolution — second, by effu- 
sion — third, by suppuration — fourth, by adhesion — fifth, by spha- 
celation and mortification. But, when you find this great ridge, 
extending down from the groin, it is because effusion has taken 
place already; and, therefore, the bleeding stage has passed by. 
It may be useful to apply some leeches along the course of the 
swollen theca, because a topical depletion tends to prevent the 
further exterior or circumferential progress of the malady; it will 
have very little influence on the essential or endangial disease. 

But, perhaps, gentlemen, the best and most efficacious of all 
remedies, is position, used in the chirurgical sense — I ought, 
perhaps, to say rest and position. The patient is to be irrecusa- 
bly confined to the dorsal decubitus; the whole limb to be placed 
upon pillows, or upon a bolster, so arranged as to incline the leg 
upwards at an angle, not above 7° or 10°. She should be told : 
"Now, madam, if you dare to put the foot upon the floor, even 
after you shall be almost cured of this disease, you will scarce 
fail to reproduce it with all its intenseness: the peril and the pain 
will be yours. Look to it, that you incur them not." Is not it 
very clear, that if she puts her foot to the floor, and stands upon 
it, she will have to lift the whole column of blood in the veins, 
from the sole of the foot to the cardiac extremity of the vena 
cava, at the expense of the most enormous strain upon the sides 



630 CRURAL PHLEBITIS. 

of the vessels ? It would be the grossest malpractice, to allow 
the woman even to sit up on a sofa, until the limb is safe. 

Our great and learned surgeon, Dr. Physick, used to be proud 
of the certainty with which he treated cases of phlebitis, by his 
method. Dr. Physick's method was to apply a blister, covering 
the whole diseased tractus of vein, a little wider than that tractus. 
If you will take my advice, you will not neglect it ; for of Dr. 
Physick's practice it may be said, " JVil tetigit quod non ornavit." 

Well, what is the next thing to be done? The limb is to be 
stuped, which should be done in this way: procure an old flannel 
petticoat — there is always a petticoat to be found where there is a 
woman — cut off the gathers; dip the flannel petticoat— the whole 
of it — into a large basin, filled with equal quantities of vinegar 
and boiling water ; the liquor should be very hot. Let the petti- 
coat be wrung out, as hard as four strong hands can possibly 
wring it, and with it let the whole member be carefully enveloped. 
To prevent the moisture of the fomentation from wetting the bed- 
clothes, a piece of blanket, or some oiled silk, should be spread 
beneath it. A blanket is better, for the blanket can be rolled 
over the whole stupe, keeping up its temperature and its moisture 
for a long time. 

My custom is to keep up the stuping for six consecutive hours ; 
after which, as the woman becomes tired of it, I cause the mem- 
ber to be gently bathed with a mixture of warm sweet oil and 
laudanum, carefully wrapping it up afterwards in fine flannel; 
and after leaving it so, for two or three hours, the stuping is re- 
commenced, and continued for five or six hours ; and so, I alter- 
nate the stuping, and the inunction with the oil and laudanum, 
until the swelling has abated, or until I can shake the calf of the 
leg. After which, I inclose the limb in a common roller band- 
age, for the purpose of facilitating and hastening absorption. 

When the woman has got well, I let her walk about; but, I 
always make it a rule to tell her, that her vein is reduced in size, 
and that it is no longer capable of carrying off from the limb, 
with the same facility as formerly, all the blood thrown into it by 
the arteries ; that if she will throw into it excessive quantities, 
by walking about too soon, or too much, she will have a swelled 
leg. Sometimes the leg continues swelled for thirty years; I have 
seen it so. Why should it not? The calibre of its vein is dimi- 
nished, and in some instances destroyed. Where it is totally 



PUERPERAL CONVULSIONS. 631 

destroyed, trie woman can never expect to have the limb as small 
as it was before the malady — she should be thankful to God, for 
her escape with existence. 

No prudent man would lay aside the charge of such a case, 
without directing his patient to wear a gaiter — to come up above 
the knee — for several months after the cure. 

C. D. M. 



LETTER XLIII. 

Gentlemen: — Among the numerous sources of that anxiety to 
which the practitioner of midwifery is exposed, is the dread that 
he often feels, lest his pregnant or parturient patient should be at- 
tacked with eclampsia, or puerperal convulsions. I say the prac- 
titioner of midwifery — for I presume that it will be found, in ge- 
neral, true, that he who has much professional business in the line 
of those maladies, that are called Diseases of Females, will be 
also an Obstetrician. 

Puerperal convulsions, or eclampsia, from sxia/irttys, a flash, is 
a convulsion affecting a woman advanced in pregnancy, or in 
labor; or one in the first days of the lying-in. 

It is a malady that is not met with every day — but it is one so 
horrible in appearance, so deadly in its tendency, so embarrass- 
ing sometimes in its treatment, that, although, as I said, it is not 
met with every day, it is solicitously expected, and probably ob- 
viated in many a case, which, but for such careful supervision, 
would sw T ell its proportions in the statistical tables. 

To show you the relative frequency of the attacks, in a given 
number of labors, I refer you to Dr. Collins' Midwifery. 

Among the whole number, 16,414 labors, under his care, 
there were thirty cases of puerperal convulsion — of which twenty- 
five recovered, and five died. This shows you, that one woman 
out of every 547, was attacked with the disease. How many 
others were guarded against the threatened attack, cannot be 
known; since, many of them may have been menaced, whose 



632 PUERPERAL CONVULSIONS. 

cases having ended happily, by being averted, do not appear in 
the statistical result. Out of 20,357 labors, under the care of the 
late Madame Boivin, at the Maternite, at Paris, the number of 
patients affected with eclampsia, was 19. So that, out of every 
thousand women in the Maternite, one was seized with the dis- 
ease. Dr. Churchill, {Midwifery, p. 447,) has collected tables of 
96,903 labors, in which 159 cases of convulsions occurred ; giving 
one in 609. 

These results, if you depend upon them, will mislead you in 
practice. They do not at all represent the risks that women run 
from this cause ; for in fact, if you become wise, sagacious, and 
prudent practitioners of midwifery, you will avert the attack in a 
very large majority of the instances that would, but for the pre- 
cautions made use of under your administration of them, add to 
the ratio in the tables. I have met with a good many samples of 
eclampsia, in the course of my obstetrical practice, but I am 
very sure that I have prevented a far greater number of attacks 
than I have witnessed. Some of those that have fallen under my 
observation, were wholly unexpected, sudden as a flash. Others 
came on after a long and anxious expectation of them, or after the 
careful and persevering employment of all the prophylactic means 
within my reach. Those means, in a far greater number of cases, 
have been employed when I had good reason to expect convul- 
sions ; but in which no convulsions occurred. I did suppose, that 
the remedies had hindered the attacks, and I still believe that 
they did so. Perhaps, however, I have many times indulged vain . 
fears for the safety of my wards, and subjected them to treatment 
that was unnecessary. _ » 

Upon consulting my case books, and taxing my memory, I find 
that I have observed twenty-four instances of puerperal convul- 
sions ; and my colleague Dr. Huston, your Professor of Thera- 
peutics and Materia Medica, informed me in 1844, that he had 
observed thirteen cases. Of those under my observation, twenty 
recovered, and four died. Dr. Huston's cases show eleven re- 
coveries, and two deaths. 

Primiparous women are most liable to eclampsia ; but all par- 
turient women are liable to the invasion. 

Of eighty-five cases that are mentioned in the work of Collins, 
seventy-three were observed in primiparous women. 

Women with short necks; those who are fat; those who possess 



PUERPERAL CONVULSIONS. 633 

considerable muscular strength; those whose tissues are firm, 
solid, hard, and unyielding; those that are of a sanguine-nervous 
temperament ; those who have swollen feet and hands, and such 
as, upon waking in the morning, complain of numbness in the 
hands and bloating of the features; those who are affected with 
a feeling of great weakness, or with loss of sensation in one side 
of the face, or in one of the members ; those who have suddenly 
lost their hearing; those who have vertigo, cephalalgia, muscee 
volitantes, flashing of light within the eyes, dimness of sight, 
double vision, or half-sight; those who have sudden loud noises 
in the ears, and such as feel as if a violent blow had been re- 
ceived upon the head ; those, furthermore, who labor under intense 
ansemia, with distension of the blood-vessels and heart — all such 
are to be held liable, and closely observed and protected. 

Puerperal convulsions consist of violent, irregular, non-spon- 
taneous innervations of the voluntary muscles, characterized by- 
strong rotation of the head to the right or left, and backwards, 
with violent jerking contractions of the muscles of the upper and 
lower extremities, back and abdomen. Spasmodic action of the 
diaphragm and muscles of expression, very rapidly repeated, 
always attend it. The lips and teeth are firmly closed and opened 
by turns, so that the rapid and violent breathing produces a loud, 
peculiar hissing sound. The tongue, which assumes a very dark 
livid color, and is almost in every case thrust forward between the 
teeth and jaw r s during the paroxysm, is often found to be severely 
bitten. The wounds of the tongue permit the saliva, and mucus 
of the mouth and throat, to be tinted with blood, which flies to a 
considerable distance through the compressed lips, staining the 
patient's face, her dress and pillows, and adding to the horror of 
the spectacle. 

The rapid convulsive movement of the diaphragm, being ac- 
companied with spasm of the glottis, the blood of the lungs does 
not receive the benefit of a true and loyal respiration. It does not 
get its full dose of oxygen, but is hurried off imperfectly decar- 
bonated to the systemic auricle and ventricle, whence it is injected 
into the brain and the whole system. The darkening hue of the 
countenance ; the deep venous tint of the tongue, and the blueness 
of the hands and feet, show that the patient is passing into a state 
of asphyxia; and she does blacken her blood more and more, until 
the brain, no longer receiving oxygen sufficient to extricate the 



634 PUERPERAL CONVULSIONS. 

nerve stream, the convulsive innervation ceases from want of the 
means to extricate any longer the nerve-force, or neurosity, as Dr. 
Cerise calls it. 

During this extraordinary scene, one in which the organs that 
are innervated by the pneumogastric nerves chiefly suffer, the 
powers of the hemispheres and tubercula quadrigemina experi- 
ence a temporary abolition, or, rather, suspension of power. And 
it is a curious reflection, that, those important parts of the brain 
should be quelled into a sort of temporary death or oblivion, while 
the spinal cord and the cerebellum, which are the sources and 
directors of the motions, and also the medulla oblongata, which 
gives origin to the respiratory nerves, should be the seats of that 
intense though irregular evolution of power, whose effects we 
witness, in the writhings, and contortions, and agonies, of the 
eclampsia. 

It is also a curious circumstance, and one well worthy of your 
attention, that the blackening of the blood, or its conversion into 
venous blood by the interruption of the respiratory or oxygenat- 
ing function, should be the means provided and designed by 
Providence for the cure of the paroxysm. When the whole san- 
guine mass has become carbonated, the brain and the spinal cord 
must cease to innervate the muscles convulsively ; and the speedy 
relaxation of every rigid muscle permits the restoration to the lungs 
of their oxygenating power ; so that, in a few moments after the 
countenance has been black and deformed in every feature, you 
have the pleasure to see it recover its whiteness, though ghastly 
pale ; while the brain, I mean the whole brain, wakes up to the 
renewed performance of its organic as well as its intellectual 
offices. When, therefore, in looking upon these frightful scenes, 
you see the face of your patient growing darker and darker, you 
will discover in that very circumstance, the hopeful announce- 
ment of a speedy close of the distressing exhibition. 

I think that, in a majority of the cases, you may expect to find 
the whole brain recover soon after the ceasing of the convulsive 
innervations ; but this is not always the case ; for, in some patients, 
I have noticed a profound coma to succeed the convulsions; the 
hemispheres, the cerebellum, and the tubercula quadrigemina, 
remaining oppressed and extinct, as to power, while the medulla 
oblongata and the spinal cord had resumed a quasi regular ex- 
ercise of their forces. 



PUERPERAL CONVULSIONS. 635 

In a case that fell under my care in this city a few years since, 
the lady had convulsions, which occupied the hours from about 
11 o'clock A. M. till near 5 P. M. During these convulsions she 
gave birth to a dead foetus of seven months ; remaining wholly 
unconscious during the process. I say unconscious, though she 
moaned a little, during the labor-pains, like a person disturbed by 
some distressing dream, or like one under the influence of ether 
in a surgical operation. Some hours after the last convulsive 
attack, and after she had been lying profoundly still, as if asleep, 
she moved with spontaneous or voluntary motion, showing that 
the cerebellum was aroused to its true office of directing or co-ordi- 
nating the power extricated in the brain and spinal cord. She soon 
afterwards spoke and recognized the voices of friends, and was 
perfectly reasonable ; showing that her hemispheres had waked up 
to their office of intellectual perception and combination. After 
having for some time spoken, and spoken well/she said, "How 
dark it is — why do you keep it so dark?" "It is not dark," 
replied I; "do you not see the candle?" "Oh no, there is 

no candle here." "Yes, dear Mrs. , here is the candle — 

see, I hold it just before your face." Her beautiful eyes were 
open, and she turned them at will, to look for the light which shone 
into their large dark pupils. "Do you not see the light?" said 
I again. " Oh no, Doctor ; w T hy do you say so? I'm sure there's no 
light here." She was totally blind : that is to say, her tubercula 
quadrigemina were still oppressed, while the rest of her brain had 
recovered, being liberated from the thraldom of the congestion. 
After some time, the dawning light of day having considerably 
increased, she perceived it, and cried out, "Why, it's daylight!" 
and I then knew that the tubercula quadrigemina had also reco- 
vered. 

There is a useful moral in this statement — it is that we should 
look to it, in the conduct of all such cases of disease, that all the 
parts of the brain recover — and that in so far as our measures 
may have efficacy, we fail not to employ them to the entire sub- 
duction of even the last vestiges of morbid action, or oppressed 
or suspended power. These vestiges of disease we may clearly 
discern in the intellection, and in the muscular innervations. 

The successive recovery of the different parts of the brain in 
this case is interesting, as it is analogous to the incidents observa- 
ble under etherization. When a patient is subjected to the in- 



636 PUERPERAL CONVULSIONS. 

halation of ether, the different parts of the brain are affected in 
succession; but not always in the same succession. The sensi- 
tive cords of the cerebro-spinal axis are, in etherization, plunged 
into a state of insensibility — leaving the hemispheres capable to 
perceive and understand what the quadrigeminal tubercles see of 
any operation that the surgeon is performing. Or, the motor 
fibres are put asleep, yet the sensitive ones communicate to the 
conscious mind the painful impressions which the mind perceives 
— but which it forgets, as it forgets a painful dream. 

If the etherization go very far, the hemispheres, the cerebellum, 
the tubercles, and the motor and sensitive cords, are all hushed in 
a profound state of aperception, both of the direct and the reflex 
influences or impressions : the medulla oblongata alone continues 
to do its work of irradiating the parts that are under the contact of 
the pneumogastric. If the ether be given long enough, and in 
quantity sufficiently great to quell its force of innervation also, the 
patient dies. Hence the medulla oblongata is called by M. Flou- 
rens the life-tie — the vital knot — le nceud-vital. The oxygenating 
power depends upon it, and without oxygen — no neurosity. Take 
away the ether in good time ; admit the pure atmosphere to the 
lungs, and the functions of the whole brain are revived — so, in our 
eclampsia, as soon as the abnormal state of the encephalic circu- 
lation gives place to a normal, or, one more nearly normal, the 
brain wakes up to its duties again, and the patient sees, hears, 
speaks and acts, with the most perfect co-ordination of all those 
vital forces that are dependent on the brain and cord. 

If, in etherization, you press the administration of the drug to 
the point of quelling the vital-tie of the medulla oblongata, she 
will die, and you will find no necroscopic lesions in the encephalon. 
So, likewise, in the speedy dissolution under eclampsia puerpe- 
ralis; the autopsia discloses no lesion of any part of the brain. 
Are you surprised that the woman should die without perceptible 
physical lesions of the brain? You are not at all surprised if she 
disclose none such when destroyed by ether-inhalation. May not 
the brain perish under the one influence as well as under the 
other, and yet, dying, leave no sign ? In eclampsia, there is al- 
ways abolition, for the moment, of the power of the hemispheres, 
always of the tubercula quadrigemina, and always (perhaps!) of 
the cerebellum. All these revive, and are extinguished again and 
again, as the paroxysms are repeated or suspended by turns. When 



PUERPERAL CONVULSIONS. 637 

the case has come to its close, and the patient is restored, where 
are the lesions? No trace of them remains. But — and here is 
the explanation — if the medulla oblongata be affected equally with 
the others, the patient dies, because the sources of the respiration 
are cut off. 

There are many circumstances, the concurrence of which tends 
to the development of the eclampsic convulsions of pregnant, 
puerperal, and lying-in women. For many women, the whole 
state of gestation from conception to labor, is a state of nervous 
excitement or hyperaBsthesia, which renders the subject specially 
obnoxious, under the application of exciting causes, to convulsive 
or irregular, non-conformable innervation. Whether this too sus- 
ceptible nature depends upon an altered crasis of the neurine, or 
whether it arises from modifications of the blood, developed during 
the gravidity, remains to be ascertained ; and it contains questions 
full of interest to the pathologist and the therapeutist. 

The sensorial system does, certainly, in many pregnancies, 
suffer from the intrusion, pressure and displacement that coincide 
with the immense augmentation of the volume of the uterus, 
which thus offers the perpetual provocation to what is termed 
irritation. 

The globe of the womb, when it has attained a certain 
volume, presses by its weight and mass, (and is by the abdominal 
muscles pressed,) against the ventral aspect of the spinal column, 
as Deventer proposed. But, the great vascular trunks that lie along 
the front of the vertebrae, suffer compression by this vast womb ; 
and in the primiparous woman, whose abdomen resists the exten- 
sion of its walls, the uterus is pressed strongly against the aorta 
and the cava ; more strongly than in those who have been many 
times pregnant. But if, in labor, the patient, in order to assist in 
the expulsive efforts of the womb, should bear down, by contract- 
ing her obliquus, rectus, and transversalis abdominis muscles, 
while the womb is at the same time hardened by the contraction 
or "pain," those great sanguiferous trunks must be so much com- 
pressed, as greatly to lessen their calibre, and diminish the flow 
of the blood through them. 

This effect is demonstrated in the swelled or infiltrated limbs 
that we meet with in the last stages of pregnancy, the oedema 
gravidarum, of which I shall here say nothing more, having given 
a full explanation of its causes in my letter to you, No. XXXVII. , 



638 PUERPERAL CONVULSIONS. 

p. 496, to which I refer you. Now, if to the habitual over-disten- 
sion of the encephalic blood-vessels, we superadd the immense 
determination to the brain, caused by the straining efforts to bear 
down; by the hope; by the expectation; by the disappointment ; 
by the stings and agonies of the labor pains ; by the heated and 
quasi febrile condition of the whole mass of the blood; by its aug- , 
mented momentum and velocity; what wonder is it to find that 
the nerves of the spinal cord, both motors and sensorials; that the 
par vagum, and the phrenic; in short, that the cerebro-spinal 
axis, over-strained, over-heated, over-stimulated, polygamic, 
should yield to the coincident action of so many causes, and 
manifest its distress in the convulsive innervation of the muscular 
system, and in the temporary suspension of the perceptive facul- 
ties? and further, that the paroxysm being over-passed, the patient 
should speedily feel as if nothing had happened? Or what need 
have we for surprise if, the patient having perished in the attack, 
we can discover, in some cases, no marks of pathological action 
in the brain ? whereas, in some other samples, we find the evi- 
dences of sanguine extravasation or of serous effusions in the en- 
cephalon, under the wild, impetuous and irresistible rapidity, 
volume and momentum of the cerebral circulation. 

A woman in puerperal convulsion, is one in whom the produc- 
tion of the neurosity is augmented beyond the control of the will; 
and both exceeding the normal rate of production, and losing the 
healthful regular distribution of it. Such a convulsion endangers 
the brain which produces it — it endangers the lungs that are also 
essential to the production of it, and the circulation, which supplies 
the brain with its oxygen, its pabulum, its tension and pressure. 
The great nerve-centres, connected by the sympathetic, and ruled 
by the par vagum, are overthrown and trodden under foot, as it 
were, in the melee ; and life becomes extinct from exhaustion, 
from engorgement, and from shock ; for all these causes combine 
to extinguish the vital flame ; and our necroscopic inquiry shows 
all the physical structures unaltered and even intact. 

The inferences I deduce from these representations is, that our 
prophylactic, as well as our therapeutical ordinances, should be 
based upon an intention to save the brain. How? By hindering 
or curing that augmented momentum and determination of the 
blood to the brain, which is the most essential element of causa- 
tion in our disease. How is this to be effected ? By controlling 



PUERPERAL CONVULSIONS, 639 

the heart's action, by the use of venesection ; by obviating excite- 
ment, by laxatives or enemata ; by laving the hands and face 
with cool water; by cool drinks; by cheering assurances; by 
order and quiet in the lying-in chamber; by abstaining from too 
frequent touching; by prompt delivery of the woman ; or by ceas- 
ing from premature attempts to deliver. 

A woman in labor, or one near her time, before or after delivery, 
who complains of headache and other cerebral phenomena, is 
always to be esteemed as being upon the point of an eclampsic 
attack; and the medical adviser should look to it, that the attack 
be not formed. For many years past, I have never heard a 
woman complain of headache in labor, or soon after, or before 
it, without at once making this reflection. Occasionally, upon hear- 
ing such complaints, I have been induced, by motives which at 
the time I deemed paramount, to abstain from very direct inter- 
ference, and I have almost invariably had cause to rue such de- 
termination. And I venture here to predict, that, if you, in like 
manner, should pass by, without regard, similar complaints made 
by your patients, you will have abundant cause for regret. It may 
be, that, upon hearing a woman in labor complain of headache, I 
may, on a very few occasions, have had no cause subsequently to 
lament that I disregarded it. However, the impression upon my 
mind at this moment is, that whenever I have so disregarded the 
complaint, I have had a case of convulsions to treat, that I might 
readily, perhaps, have postponed, or wholly averted by giving to it 
the attention it really demanded at my hands. Within a year, I sat 
at the bed-side of a lady in labor, which was making a perfectly 
satisfactory progress. After a pain that she had, she said to me, 
"Oh! how my head aches, doctor." I immediately rose, and ex- 
amined her pulse — for in her preceding confinement she had a 
frightful attack of eclampsia, on account of which I had bled her 
to a very large amount. Her health had never been very good since, 
whether in consequence of the derangement of her nervous system 
that expressed itself under the form of convulsion, or whether on 
account of the large abstractions of blood. As she approached 
the term of the present gestation, she had repeatedly complained 
of headaches; flashings of light j tinnitus aurium ; suiliisions of 
the face and forehead ; on which account I had dieted and bled 
her, so as to have placed her, as I supposed, in a condition favor- 
able enough, as regarded the expected conflict of labor. 



640 PUERPERAL CONVULSIONS. 

When she now complained of this headache, I inquired as to 
its degree, place, &c, and as it very soon went off, I was averse 
to ordering the farther loss of blood, the more particularly, as the 
child was quite near being born. / did not bleed her. She had 
two or three consecutive pains, after each of which the headache 
returned, but it was slighter. I resumed my seat, in order to take 
care of her at the moment of the delivery. A pain came on, and 
with it a short, quick, loud, hissing sound from her lips; her head 
rolled strongly in extension to the left ; her hands, arms, lower 
extremities, and indeed all the voluntary muscles, as well as the 
diaphragm, were in the most intense convulsions. I am as sure 
as that I am now recording these events, that she would not have 
had the convulsions, had I bled her ad deliquium, when she first 
said, a Oh! how my head aches, doctor!" The convulsions were 
repeated, so that she lost her life, to my great and lasting regret. 

Perhaps some of you may be inclined to adopt the opinion that 
in the management of a labor, in which fear is entertained by 
the physician of eclampsic seizure, there is danger of its being 
brought on, and not averted, by the use of the lancet, agreeably to 
the reasons set forth by that able and distinguished physician, Dr. 
Henry Holland, in his "Medical Notes and Reflections." Dr. 
Holland, at p. 52 says, "the use of the lancet is easy, and gives 
a show of activity in the practitioner, at moments when there 
appears peculiar need of this promptitude ; current opinions and 
prejudices are wholly on the side of bleeding; and the complexity 
and danger of the cases tend to obscure the results of the treat- 
ment pursued. The physician needs all his firmness to decline 
a practice thus called for; when the event is so doubtful, and 
where death may be charged upon his presumed feebleness, or 
neglect." Dr. Holland, while making these remarks, neverthe- 
less recognizes " in the fullest sense, the value and need of this 
remedy promptly and vigorously used, in various cerebral dis- 
eases, or in prevention of such, where well marked symptoms 
lead to their anticipation." 

Should you admit any apprehension as to the liability to in- 
vite, instead of preventing the epileptiform convulsion of labor, 
by venesection, I trust you would take into consideration the very 
peculiar condition of the parturient patient, who is rarely found 
able to disembarrass herself of the fruit of the womb, without a 
most intense application of voluntary tenesmic force, in addition 



PUERPERAL CONVULSIONS. 641 

to the more normal uterine power; and, that the exercise of that 
voluntary force is invariably attended with the signs of augmented 
encephalic determination. The sound and philosophical cautions 
of Dr. Holland, therefore, cannot apply to the instances of epi- 
leptiform attacks or menaces for the parturient woman, however 
earnestly they ought to be inculcated for some, — nay, many of 
the extra-gestative cases. 

M. Flourens' experiments on the brain have thrown so clear a 
light on the symptoms that attend the encephalic disorders, that 
the path of the therapeutist is made straight for his cotemporaries. 
To show you clearly what is the nature, and what the appropriate 
treatment of our disorder, I ought, perhaps, to present you an 
abstract of his results. But, in fact, I have already done that for 
you, in placing within your reach, M. Flourens' little tractate, 
called " Phrenology Examined" a book which you could not 
read (and one may read it through in an hour), without finding 
much of the difficulty both of comprehending and treating puer- 
peral convulsion, obviated, or indeed nullified. 

M. Flourens' results, then, can be applied to the diagnostica- 
tion of the state of the brain, and its several parts ; and when you 
see the co-ordinating brain (the cerebellum), exerting its force 
abnormally, while the reasoning brain (the hemispheres), is either 
in a natural state, or stupefied with coma, — and so of the other 
parts of the brain, — you will readily decide as to whether the signs 
demand, or forbid, the use of the lancet. 

If I were treating a woman in labor, seized with the true puer- 
peral convulsion, I should certainly bleed her — provided the con- 
vulsion did not cease before I could effect my purpose — and should 
T, in any such case, open the vein, I should surely allow the stream 
to flow as long as any convulsive innervations were left unquelled. 
Provided the convulsion should return again, I should bleed her 
a second time, and allow the blood to flow until the spasmodic 
and convulsive phenomena should have again disappeared. I do 
not say I should do so a third time, and a fourth, though I have 
done so heretofore. I should act thus, because I cannot conceive 
of such a convulsion, in a person who has been sufficiently ex- 
hausted by venesection — since in such a person, the brain would 
be left incapable of issuing a sufficient amount of nerve-force to 
give rise to such phenomena. 

After bleeding the patient, I should deem it, in almost every 
41 



642 PUERPERAL CONVULSIONS. 

instance, proper to procure a copious alvine dejection, by means 
of an enema — one, or more. The article most suitable, because 
it is the most convenient, is common salt, dissolved in warm water ; 
two large tablespoonfuls of salt, dissolved in a pint of water, 
should be thrown into the rectum. This is so very powerful an 
excitant of the bowel, that it may be expected to operate within a 
few minutes, but it should soon be repeated if the first one fails. 

Upon the operation of the enema, a judgment may be formed 
as to any further necessity in the way of procuring alvine dejec- 
tions ; and whenever it is ascertained that enough has been effected, 
advantage ought to be taken of the counter-irritant and revulsive 
power of the sinapism — accordingly, two large sinapisms, one to 
each leg, ought to be applied, and left in situ for some thirty 
minutes — not longer. 

The next step should be to administer the opium. Everybody 
now gives opium, in puerperal convulsions, as soon as the de- 
pletion has been carried sufficiently far, and the bowels have been 
relieved by the enema. 

A good dose ought to be given, say forty drops of laudanum, or 
twenty of the black drop ; or two grains of powdered opium ; or 
fifty drops of laudanum as an injection — fifty drops of laudanum 
mixed in a fluidounce of clear-starch, is the proper mixture. 

If the coma, with stertor, continues, the question will arise as to 
cups or leeches to the temples : let that question be settled by 
careful inquiry as to the state of the circulation in the brain. 
Such applications are often useful. 

The head should be kept cool. This cannot be properly done 
if the patient have a great quantity of hair. The hair, then, ought 
to be sacrificed. It should always be removed in eclampsia: and 
an objection will never be made, when the physician speaks with 
the proper tone and authority. To cut off the hair, and cover the 
head with an ice-bladder, or with cloths strongly wrung out of 
cold water, is indispensable. The cloths should be frequently 
changed. 

The doses of opium ought to be repeated from time to time, as 
long as the mind of the patient, and her muscular actions, con- 
tinue to exhibit the direct influence of the paroxysm. But, when 
the reason returns, and the intelligence is re-established — and 
when the convulsive innervations of the muscles are at an end, 



THE BREAST. 643 

there may be no farther occasion to repeat the doses of opium — 
or at least,, no reason for continuing them at the same rate. 

I am not writing a book on Obstetricy, and I shall therefore 
not speak of the delivery, except so far as to say, that the woman 
ought to be delivered as soon as possible ; because, the child being 
taken away, one great cause of, and provocation to, the eclamp- 
sia, will be removed along with it. By the words " soon as pos- 
sible," I mean, as soon as it can possibly be done with propriety. 
Of that propriety the accoucheur must be the judge — yet no one 
can be held excusable, who absolutely forces the os and cervix 
uteri. This is a doctrine on which Dr. Dewees used to dwell with 
great emphasis. The os uteri is never to be forced. But, there 
is a wide difference between forcing it and persuading it to yield. 
It may be prevailed against, by means of the relaxing influence 
of belladonna ointment applied to its surface, or by gentle dilata- 
tion with the hand. But, I am lapsing into a discussion in Ob- 
stetricy, and shall therefore cut it short, by bidding you farewell. 

C. D. M. 



LETTER XLIV. 

THE BREAST. 

Gentlemen : — I found her lying in bed, and looking dull and 
dispirited, when I entered the apartment; whereas, I had parted 
from her two days before, in excellent spirits, proposing to get up 
on the morrow; for by that time, her ninth day, the dies nondincz 
would be complete. The child was in health; she had had an 
excellent labor ; the flow of milk was abundant ; and not the slight- 
est untoward event had occurred up to the end of the eighth day. 

"I am sorry to find you have been obliged to send for me, my 

dear Mrs. . I left you so well the day before yesterday, 

that, being much occupied, I thought I might lay aside my daily 
habit of coming to make you a salara in the morning; — you know 
that I have had nothing else to do since the birth of the infant. 



644 THE BREAST. 

You were cheerful and happy when I saw you last; but now you 
look downcast and apparently sick. What can be the matter with 
you?" 

"I have been quite sick, doctor, since yesterday afternoon." 

" What! quite sick, and I not notified of it? Did you not say, 

did not this nurse say, did not Mr. B say, that if, at any 

time in the whole course of the month, you should be seized with 
any symptom whatever, great or small, I should immediately re- 
ceive a note, informing me of it? Here, now, you've been sick 
almost twenty hours before I am made aware of it. Was this 
just to me ? Was it just to yourself and your friends ? However, 
I suppose it will always be so with everybody, since I have found 
it so with everybody for thirty-seven years." 

"But, the Doctor will please to observe that we did not like to 
trouble him. It was thought that the indisposition might readily 
pass away; and, indeed, I do feel a little better now than I have 
done in the night, or the early part of the morning." 

" But what has been the matter with you ? What have you 
complained of since yesterday afternoon?" 

"I was taken with a chill, sir, at two o'clock, and I could not 
get warm for near two hours. This was accompanied and fol- 
lowed with pain in the head, in the back of the neck, and in the 
limbs, that I could hardly endure; and I became so warm, that I 
was obliged to throw off some of the coverings." 

"Have you any pain in the stomach or bowels?" 

"No sir, not the least." 

" Can you draw up and extend the lower extremities without 
pain? Try it; does it hurt you ?" 

"No, sir." 

" Cough — I wish to know whether, if you cough, it will give you 
any pain in the lower part of the bowels. There ! that will do. 
Does that hurt you,?" 

"No, sir, it does not." 

" Make a great aspiration of air for me. Breathe hard. Any 
pain?" 

"Not the least, sir." 

"Which of the breasts hurts you?' — the right or the left one?" 

" My breast doesn't hurt me, doctor." 

"Yes, it does." 

"No, doctor!" 



THE BREAST. 645 

" But, I am sure that it does; and that the cause of your chill, 
and of the heat that you have had all night, and that you still 
have — for your pulse is quick — is seated in one or more of the 
branches of the milk tubes. Will you let me touch the breast?" 

"Yes, sir." 

"There, now, it hurts you at this point, does it not ?" 

"Ouch! Oh yes, sir! yes, sir, very much, indeed! Why I did 
not know that I had anything the matter with the breast !*' 

"But I did, you see." 

"Yes, I see that you did. It is very strange that you should 
know that I had a pain, when I myself didn't know that I had 
it!" 

"No, it is not at all strange; it is very easy to know that; 
because it is very easy to perceive, in the rate of your pulse; 
your breathing; your heart; in the tint of your complexion; in 
your physiognomical expression; in your gesture and attitude; in 
the absence of pain in the abdomen; in the state of your intellect, 
evinced by your answers to my questions, that nothing else could 
be the matter with you. In fact, as soon as you said, 'I had a 
chill yesterday afternoon,' I knew that you had an attack of what 
the ladies and nurses call the w T eed. You have got a milk-fever, 
my dear." 

This conversation happened yesterday morning, Nov. 20th, 
1847. To-day, the patient is very well again, for the weed has 
disappeared ; that is to say, the milk which had accumulated in 
excessive quantities in the lactiferous ducts of the mammary 
gland, or rather in certain of them, has been carefully drawn out; 
and the tension, pressure, irritation, intension, affluxion, heat, 
sensibility, redness, and swelling, all disappeared upon its evacua- 
tion. 

I have been practicing my art now for a great many years, and 
I must have seen-some hundreds of persons lying sick as this lady 
was ; some of them with intense fever, cracking headache, intole- 
rable pain of the nucha, back, and limbs, not ^infrequently with 
nausea and vomiting, and all this mixed up with distressing flying 
rigors — to whom I have said at once, "you have got a lump in your 
breast ;" to which it has often been replied, " no, I have not." 

"Yes, you have." 

"No, indeed I have not." 

"Indeed you have." Whereupon the nurse rejoins, "Oh no! 



646 THE BREAST. 

there is not any at all, for I examined the breast very carefully, 
but just now." 

" Let me examine it. There, now, does that hurt you?" 

"No, not at all." 

"Does not thatV 

"Oh! dreadfully, dreadfully indeed!" 

" I told you so. It could not be otherwise. How should it be 
that I should not understand my business ? I could tell you had 
the weed in your breast, if you were in the moon, and I w T ere 
looking at you with a spyglass." 

If you are going to practice midwifery, my young friends, you 
will have to submit to the aid of what are called nurses ; and sup- 
pose you should meet, during your career, with a thousand differ- 
ent ones, you w T ill not find more than two or three of them that ever 
saw a gathered breast. A man would as soon acknowledge that 
he had stolen a sheep, as a nurse confess in general that such an 
accident had ever befallen one of her patients. I saw a little dar- 
ling of a woman here, about two months ago, more patient than 
St. Anthony — who had been about two weeks confined. I had not 
seen her for four or five days. Upon receiving a summons, I re- 
paired to her house, and found her complaining of pain on giving 
suck to her child; — pain in the nipple, extending back over the 
breast, towards its upper and exterior circumference. I took the 
breast between my thumb and four fingers, so as to compress the 
gland in the direction of its latitude or breadth, and found that 
gentle pressure gave her very severe pain. Upon touching it per- 
pendicularly, I discovered a mass of solidified texture, about two 
inches and a half in width, by three and a half in length; and, 
when I learned that she had had uneasiness in the breast for four 
or five days, I said to the nurse : " Did I not charge you to in- 
form me if anything should be the matter with my patient ? telling 
you to watch her in my absence, in order that I might have the 
earliest intimation of any accident or disorder that might affect 
her? Your disobedience has brought her in danger of a mam- 
mary abscess, which may make her ill for three, or even for six 
weeks, during which she will experience much pain and con- 
stitutional irritation. You have done very wrong; you have 
failed entirely in your duty to this person, who employed you to 
take care of her ; — you have not taken care of her. I am afraid 



THE BREAST. 647 

that she'll have a gathered breast, notwithstanding everything I 
can now do to prevent it." 

"Not she, doctor!" replied the nurse, " not she, indeed! I 
have nursed for twenty years, and I have never had a gathered 
breast yet, in anybody that /took care of." 

" Very w T ell, Mrs. Nurse ; you are about to extend the area of 
your experience, in this very case ; for I think it is very likely that 
you will have two; and I wash my hands of them ; for the blame 
is yours, and nobody else's. The right breast is gone so far, that 
I have no hope of curing it, short of a suppuration. The left one 
is inflamed, and the fever that your patient is going to have, will 
cause it also to suppurate, or I am very much mistaken." 

This poor lady had two of the most detestable mammary ab- 
scesses that I have seen for the last four or five years. 

Now, I have related this story to you for this purpose, namely, 
as an introduction to the precept, watch your patient yourself, for 
you cannot get anybody, for love or for money, to do your w r ork 
as it ought to be done. You may lay down the most definite, 
clear, precise directions as to the management of the breast, and 
you will be sure to be disobeyed. If the breast will take care of 
itself, and not get into disorder, it is well ; but, it is very apt, in- 
deed, not to take care of itself, and to subject you to the mortification 
of an attendance upon a mammary abscess, — always the source 
of displeasure, disappointment, and irritation in the family; and, 
to a certain extent, of blame to the physician. It touches the 
nurse in a point of honor, to suppose that her patient could have 
a gathered breast, because she considers that her official function 
consists in taking care of the breast; and you might as well tell a 
physician that he does not understand the Harveian circulation, as 
to express any doubt as to the competency of the monthly nurse, 
to the entire charge of all the circumstances connected with lac- 
tation. I should in vain endeavor — devoting many pages of this 
letter to the purpose — to express the thousandth part of the vexa- 
tions and mortifications that I have experienced for more than 
thirty years, from the ignorance, carelessness, and presumption 
of those in whom I have been obliged to put my trust. There are 
happily some nurses one can trust ; but their name is not legion. 

But, I began this letter, designing to speak of the management 
of the female breast ; let us proceed, therefore, to inquire what 
the breast is, its condition in gestation, and in the lying-in state ; 



648 THE BREAST. 

and what are the cares that it demands at the hands of the medi- 
cal attendant. 

Beneath the skin on the front of the chest, there lies — one on 
each side — a fascia, which sends up fibrous and cellular digita- 
tions to attach it to the inner surface of the derm. Between these 
frequent digitations, exist many adipose cells that often are found 
to contain great quantities of fat, so that between the external 
surface of the. fascia and the internal surface of the derm, is a 
chosen seat for the deposit of the adeps that gives to the breast 
its beautiful hemispherical form, its smoothness and softness. 
Within this fascia, of which I just now spoke, are to be found 
fifteen, and in some instances as many as twenty-one, efferent 
ducts of the granules of the milk gland, or mammary gland. 
Each of these ducts, called milk-vessels, passes out of the gland 
through the skin at the extremity of the nipple. The nipple is, 
in fact, a fasciculus of milk tubes, or galactophorous tubes, 
which are gathered up into a bundle, and protected amidst a 
number of blood-vessels, some cellular tela, nerve fibrils and ab- 
sorbents, within a very delicate derm, and a cuticle that should 
rather be called an epithelium. There is also a good supply of 
apparatus of sebaceous secretion, by means of which the delicate 
surface of the nipple is kept in a soft and unctuous state. 

Each one of the milk tubes contained within the fascia of the 
gland, runs right and left, or perpendicularly upwards, or down- 
wards, as it divides into numerous branches, becoming finer as 
they go inwards from the nipple, and successively dividing, until 
each of the minute tubuli terminates in a spherical hollow granule, 
big as a white mustard seed, from the inner surface of which the 
milk is secreted ; for that is the secreting surface of the milk. 
Fifty, one hundred, or any given number of these granules, are 
appropriated to the supply of a quantity of milk, sufficient to fill 
up and distend its own galactophorous tube, whose issue is found 
upon the extremity of the nipple. 

If you had a syringe filled with delicate size, colored with ver- 
milion ; and if you should introduce the point of the syringe into 
one of the milk pores upon the end of the nipple, you might inject 
the milk tube, and distend it so much as to make it swell out to 
the size of a large swan quill, or, in some instances, to the size 
of your little finger. If the material of the injection should run 
inwards into every branch of the galactophorous tube, so as to fill 



THE BREAST. 649 

each granule at the extremity of its branch, you would make a 
beautiful injection of that part of the lactiferous apparatus. If you 
should afterwards fill the syringe with other colors, green, black, 
blue, yellow, orange, violet, indigo, or any of them, you might 
inject, in succession, each of the fifteen or twenty-one porules at 
the end of the nipple, with a different colored mixture, and thus 
fill up the breast completely with various colored injections; each 
of which would run off to the branches of its own particular galac- 
tophorous tube, and nowhere else ; so that you might say, as in 
boxing the compass, this one runs north, this one north by east, 
northeast, southwest, south and by east, northwest, west, and so 
on, until you have indicated the direction of each tube separate 
and distinct. Such is the anatomy of the heart, as explained by 
Sir Astley Cooper in his delightful work on that subject. 

Now, these galactophorous tubes are supplied with the mate- 
rial for secreting an immense quantity of milk, consisting of a 
mixture of water, albumen in solution, casein, and oil which you 
call cream. I have seen a woman, using a common breast tube, 
draw out two large tumblerfuls from one breast, at one sitting ; 
not that she had two large tumblerfuls in the breast when she 
began to draw it, but that she began to form, and continued to pour 
out, this peculiar compound, which we call milk, until the power 
of the gland to produce it being exhausted, it at length gave up 
the last drops ; demanding rest for half an hour or an hour, until, 
recovering its secretory power, it was ready to give up as much 
more. A good cow has an udder, which, if you could cut it off, 
you could readily put into a very small pail ; yet this same cow 
is capable of giving sixteen quarts at a drawing, which may 
serve to show you the rapidity with which these extraordinary 
organs are capable of pouring out the material to serve for the 
nutrition of the young. 

It must be clear to your minds, that such a great functional 
force cannot exist independently of a vast supply both of blood 
and of nerve; and accordingly numerous arteries, coming from 
within the axilla, and from the internal mammary artery; and a 
great variety of nerve fibrils, some of which are connected with the 
sympathetic, passing from within the chest, and others connected 
with the axillary branches, connecting it with the cerebrospinal 
system of innervation, serving to ally the mammary gland to the 
whole nervous constitution of the woman, and to render it in the 



650 THE BREAST. 

highest degree liable to those development movements, that result 
in sanguine engorgements and inflammations. 

At the period of puberty, among the first signs of the change 
about to be effected in the constitution of the young girl, those 
that take place in the breast are observable. The granules of the 
gland, and the efferent ducts, the galactophorous tubes, acquire 
a more positive development; and the hemisphere of the mam- 
ma begins to rise from the general surface of the bosom. But it 
becomes protuberant, rather from an increased disposition to the 
deposit of adipose matter among the cellulo-fibrous digitations of 
the gland, than from actual development of the substance of the 
glandular matter itself, although that does, as I have said, in- 
crease a little. The nipple, at this period, is very small, and it is 
seated in the centre of the aureole, which is a reddish or rosa- 
ceous area, extending from the base of the nipple to a certain dis- 
tance on the organ, in general not more than half an inch from 
the nipple, in every direction. Observe, that it is of a rosaceous 
hue, deeper or paler, according to a sanguine, or lymphatic, or 
nervous temperament of the subject. As the young girl becomes 
more and more perfectly developed, the breast becomes more and 
more augmented in size; so that you should expect a young per- 
son of eighteen or twenty, to have a larger one than a girl who 
has just changed. 

The breast in general, is possessed only of such sensibility as 
appertains to the tactile power of the skin everywhere; but, upon 
particular occasions, it is different. For example, many young 
persons at the approach of, or during the mensual period, find 
the breasts a little larger and fuller, and more sensible; and 
affected with sharp pains and aching, which disappear when the 
catamenia begin to flow freely, and reappear at the next mensual 
epoch. 

When a woman becomes pregnant, the breast very speedily 
begins to grow larger ; the fat deposited upon it is sensibly in- 
creased in quantity, and if the gland be taken between the thumb 
and four fingers, it is found that the fascia which encloses the 
materials of the gland, is fuller, and more tense, and has a granular 
feel ; in many, it feels as if it were full of strings or ridges, giving 
in some women, a sensation as if it were filled with hard earth- 
worms. At the same time this process of augmentation within 
begins, the aureole increases its area, and, what is very singular, 



THE BREAST. 651 

and worthy of your observation, the corpus mucosum of the skin 
beneath the aureole, acquires the power of excreting pigmentum 
nigrum; just as if the corpus mucosum had now become endowed 
with a pigmentary membrane, like that that lies beneath the skin 
of a Negro, a Malay, or an American Indian ; but which does not 
exist beneath the skin in the Caucasian race. In some women, 
the breast grows fat at such a rate, that the skin is pushed off, 
further and further from the fascia which encloses the gland ; and 
the milk tubes within, whose termini are upon the nipple, fail to 
stretch or elongate themselves pari passu with the rise of the skin. 
The nipple seems to be drawn inwards, so that, instead of its being 
a prominent mamilla upon the breast, there appears a depression 
like that which the carpenters call a countersink. This counter- 
sink of the nipple is produced in the same way as the countersink 
is produced in the navel of the young growing child ; for as the 
navel is held in, according to Billard's description, by the re- 
mains of the two umbilical arteries and the umbilical vein, so the 
countersunk nipple of the female breast is detained by the un- 
yielding galactophorous tubes, which refuse to be elongated while 
the rest of the tissue is being stretched. I suppose, gentlemen, 
that if our American ladies were in the habit of supporting their 
bosoms with the pretty Greek strophium, or Roman fasciola, which 
they were accustomed to wear in olden time, there would be less 
occasion to deplore the frequency of the troublesome countersink 
of the nipple. If the breast were left free to grow in all its parts, 
it is likely that the nipple would be produced, along with the rest 
of the tissues; but the wearing of corsets and busks must neces- 
sarily interfere with the development of the organ, and lend a 
material aid to the nipple, in its refusal to come forward, along 
with the rest of the structures. 

A young married woman, who should become pregnant, and 
who should find that her nipple is becoming countersunk in this 
way, should apply to the point of the breast a concave disc of 
very thin hammered silver, three inches in diameter, with an 
opening sufficiently large to allow the nipple to pass freely through 
it, and having a cylinder, a quarter of an inch in length, soldered 
upon the edge of the opening. The concave of the disc would 
adapt itself to the form of the breast, and the nipple projecting 
through the opening, and protected by the cylinder, would have a 
constant tendency to come forward, and draw with it its whole fas- 



652 THE BREAST. 

ciculus of galactophorous tubes ; so that, at the termination of the 
gestation, the nipple might be found in a fit condition to be seized 
by the lips of the child, instead of vexing it, and tormenting its 
parent with vain attempts to get it into the mouth. I have seen 
several women who could not nurse at all, on account of this coun- 
tersink of the nipple. All such are liable to irritation, and even to 
suppuration, in consequence of the impossibility of expressing the 
milk, formed in abundance by the granules of the gland ; and from 
abrasions and cracks of the nipple, produced by repeated and 
protracted attempts made with breast-tubes and pumps and various 
apparatus for what is called drawing the breast. After the above 
explanation, should you be consulted beforehand, as to the treat- 
ment of the affection, I should think you will have no difficulty 
in giving directions conformable to the wants of the patient. 

Ladies will sometimes ask you, whether it is advisable to have 
the nipple drawn by a young puppy, or by the mouth of a friend 
or servant. Let your answer be, that God is all wise ; that he 
could not make a mistake; and that if it was necessary to have 
the nipple drawn before the child was born, he would have had 
the child born before its time. All the laws of life are generic 
laws; they cannot err; and it is perfectly ridiculous, for a mere 
human reason to dare to be superior to the will of God, as it is 
expressed in the simple words, "the laws of nature." Tell 
her to let it alone; it is just as reasonable to draw the nipple be- 
forehand, as it is to give ether to put a stop to the pains of labor. 
Let her know, that after her child shall be born, she will, after 
the third day, or earlier, put it to the breast; and that the mo- 
ment the child begins to irritate it with the tongue and lips, 
she will begin to feel an after-pain — that is a contraction of the 
womb — for there is now a connection between the breast and the 
uterus which affects them both interchangeably. To draw the 
breast, therefore, is to expose herself to the risk of exciting the 
action of the womb before the time. Surely, to draw the breast 
is to excite the womb into muscular activity ! 

Somewhere between the first and seventy-second hour after the 
birth of the child, the fluxional movement towards the mammary 
gland, begins to take effect ; and the determination of the develop- 
ing-force of the economy proceeds in the direction of the secretory 
offices of the granules, manifesting itself by the production of the 
milk, which flows into the great tubes of the breast, making it 



THE BREAST. 653 

hard, voluminous, hot, weighty, and painful. The whole of the 
gland being contained within its fascia, and being now greatly 
increased in weight, it hangs suspended upon the skin on the front 
of the thorax, and prolapses, stretching the skin, and often in- 
creasing the pain of the gland in consequence of the unequal ten- 
sion of the several parts of it, caused by its descent. The breast 
should always be held up ; it should never be allowed to hang by 
its own tissues. You would not think of treating an orchitis 
without a suspensory; nor should you think, in like manner, to 
take good chirurgical care of an overfilled breast, without pro- 
viding good means for its support. A Greek or a Roman girl 
always supported her breast by means of the strophium, or fasciola, 
which passed beneath it — you should provide a strophium for 
your patient. The most convenient one that can possibly be de- 
vised, in my opinion, is a linen strip of adhesive plaster, half an 
inch wide and ten inches long, placed upon the skin behind the 
breast on the side: it should be attached to the hemisphere, 
which is to be held properly upwards, and the upper extremity 
being carried upwards near the clavicle, should be adapted in 
such a way as to assist the corium to hold up the breast, charged 
full of fat, and granules, and bundles of milk tubes. This is 
far better than all the jackets, and corsets, and pocket-handker- 
chiefs that can be devised — I mean for the early stages of the 
lactative breast. The adhesive strip should be reapplied every 
second or third day. 

In most cases, you would think a suspensory a sufficient 
remedy for an orchitis; in like manner, you will find that an ad- 
hesive strophium is sufficient for the slighter irritations of the 
female breast. You may apply it so as not only to support, but 
gradually and favorably to compress, the whole organ. 

When the breast becomes filled, its sensibility is so greatly in- 
creased, that the woman does not willingly suffer it to be touched. 
You will often find it incompressible, and actually shining from the 
polish of its tension. It has a power to irritate the nervous and 
vascular systems equal to the power of an immense imposthume 
or abscess ; and the constitution will be found to react upon it ; and 
the woman will have a fever, ushered in with rigors, or even with 
a severe ague. These rigors and fever, like those of an ordinary 
intermittent or remittent, terminate in a copious perspiration. 

The fever is not a tertian, it is an ephemera; it terminates after a 



654 THE BREAST. 

course of nineteen hours from the beginning of the cold to the end 
of the hot stage: this is its natural course. But then, a milk-fever 
is not a matter of indifference ; because, a milk fever attacks the 
constitution of a woman, when greatly modified by gestation and 
labor, and the puerperal state; and if the violence of the vascular 
movement happen to be very considerable, or if there have been 
any topical lesion, or accident, that may have happened in the 
course of the labor, it is apt to invite the fluxional movement upon 
itself, and thus become a new radiant point, whence inflammation 
may extend, into the depths of the tissues, or along their surfaces. 

Don't say, therefore, "it is only a milk-fever," and requiring no 
special care ; but give it the attention it may deserve. If the milk- 
fever should be progressing favorably, and manifest a tendency to 
run out its natural course, and terminate at its term, your only duty 
w T ould be to watch it, and take heed that it do no mischief within 
the bounds of the economy. Remember, the milk-fever is a 
constitutional irritation developed from a radiating point, videl., 
the over-sensitive, over-tense tissue of the mammary gland; and 
see, in the reflection, that one indication of treatment is to de- 
prive the breast of this patho-radiant power. Well, but to deprive 
it of this power, you must make the tissues as flaccid as possible. 
How? What is it that chiefly renders them tense? It is the 
twenty-one milk tubes, whose trunks and branches are all distended 
to the extremest degree of tension, because they contain, at one 
time, eight or ten ounces of milk, constituting, perhaps, one-third 
of the whole weight of the organ. Take the milk out, and the 
breast that you could not indent with the palps of your fingers, 
will be left perfectly flaccid, completely cool, and admitting of 
the freest palpation and handling, without the woman making 
any complaint. 

Tell the nurse to put the child to the breast often. How often? 
As often as it is necessary. How often is that ? As often as the 
breast becomes hard. For thirty years past, I have told my 
monthly nurses these things; perhaps in these very words; never* 
theless, I cannot, to this very hour, go into a lying-in room, where 
I find a breast in a state of tension, and the constitution in a state 
of fever, without being told, "I did draw the breast, Doctor; the 
child took it this morning." 

"How long ago, nurse?" 

"Why, at seven o'clock." 



THE BREAST. 655 

"What o'clock is it now? twelve, is it not?" 

" Yes, it is twelve o'clock." 

" So you drew the breast five hours ago, did you?" 

"I drew it at seven o'clock, sir." 

" And it has been as hard as a paving stone ever since. Can't 
you see, that if you let the breast remain hard, it will inflame? 
This fever will increase and not lessen, and you will expose your 
patient to the risk of having a Mammary abscess, or gathered 
breast, as you call it." 

" Oh! never do you mind, doctor; I never had a gathered breast 
in my life. Do you think I ever allowed a patient to have a 
gathered breast?" 

Excuse me, gentlemen, for writing in this style, for I have at 
this moment under my care two mammary abscesses produced 
by the faults of two most excellent monthly nurses. 

I am sure, that you will be able to appreciate the importance 
there is of keeping down this mammary tension; for, if it is not 
kept down, the tissues must inflame ; and inflaming under such 
circumstances of great constitutional fluxion, you will not be able 
to avert the mischief of the threatened suppuration, except at the 
expense of the most vigorous antiphlogistic means. To draw the 
breast now, and not by-and-by, is to save the patient from vene- 
section, from leeching, from cathartics, from a disgusting series 
of poultices, and all the pain and exhaustion of protracted and 
difficult mammary suppuration. Take heed of it, then : see if you 
shall be able hereafter to be more successful than I, in making the 
patient herself, or those that attend on her, comprehend the true 
influences of mammary tension. 

When you find that the tension of the breast produces a consti- 
tutional reaction of great violence, and that the fever is accom- 
panied with headache, pain in the neck and loins, aching of 
the limbs, and frequent rigors, you should look upon it as a serious 
matter; which, though it be nothing more than a milk-fever, ex- 
poses the woman to the risk of dangerous local engorgements and 
inflammations. 

You should lessen the constitutional reaction, by opening a vein 
in the arm ; by the exhibition of a cathartic medicine, whether 
saline or otherwise; by proper doses of the neutral mixture, and 
by insisting upon the free use of demulcent and diluent drinks. 
If you allow the fever to rise to too high a grade, it may be feared, 



656 THE BREAST. 

that, instead of coming to its term in nineteen hours, it will be- 
come a continued fever, which will have an inflammatory cha- 
racter, and which may plague you for a week or ten days ; involv- 
ing you in the constant necessity of watching over the patient ; 
and exposing her to the greatest risks. 

Sometimes, the breast becomes so hard, so rebellious, that it is 
found impossible to extract the milk from its tubes; they crowd 
each other, acting as compressors upon each other; making it 
impossible to remove the accumulation. Under these circum- 
stances, the nipple is apt to become irritated and even inflamed. 
The frequent sucking of the nipple by the child, or by various 
instruments invented for the purpose, produces cracks and abra- 
sions of the surfaces, and then you have an ulceration established 
upon an inflamed base. Were the ulceration seated upon a non- 
inflamed base, it would cure itself; but you will no more cure 
the nipple-sore, while the nipple itself is in a state of inflamma- 
tion, than you will cure a cancer-sore, while the ulcer is seated 
upon a carcinoma. I do not mean that it is incurable as the can- 
cer sore is, for the nipple will get well, having in it no hetero- 
logue character; the cancer will not get w T ell, for it rests upon a 
heterologue base. 

You can have, at present, no idea of the vexations that women 
endure in nursing their children in the month/from sore nipples ; 
a complaint so common that I am always surprised w x hen I hear 
one of my patients say she does not suffer from it. 

The sore-nipple most frequently consists in a long narrow 
ulcer, w 7 ide as a horse hair, and a sixteenth or sometimes an 
eighth of an inch long. This ulcer is so small that it requires a 
good light to see it ; and even then it often cannot be detected, 
except by bending the nipple over to the opposite side, which 
discloses it. The ulcer is, at most, a narrow line of painful gra- 
nulations; and it hurts the woman so very much, as to render her 
unwilling to suckle the child as often as it should be done; 
which exposes her to the risk of having an overfull breast. I 
think it very probable that many cases of mammary abscess owe 
their origin to the reluctance of the mother to encounter the 
pangs of suckling the infant while these fissures or cracks of the 
nipple are uneured. When one of them occurs in a nipple the 
whole substance of which has become inflamed and hardened, it 
is very difficult to cure it; and it is even difficult to prevent it 



THE BREAST. 657 

from increasing both in length and breadth, since as often as the 
child takes the nipple into its mouth to stretch and to pull it, so 
often is the sore liable to be augmented. The pain is represented 
to be of the most intolerable kind; and it must be, indeed, most 
insufferable, to judge from the appearance of the mother, from 
whose eyes the tears are seen to pour as she submits to the pain. 
I have often imagined the pain to be, in intensity, very similar to 
that which one feels who has received a bit of sharp angular sand 
in the eye, and which vellicates the lid or the globe, whenever 
they are moved, producing a pain and irritation that are truly 
intolerable. The sore would disappear, I presume, in forty-eight 
hours, were it not for the necessity of drawing the breast. 

In treating such a sore, I generally avail myself of the anti- 
phlogistic and anodyne power of the nitrate of silver, the contact 
of which is, in some instances, sufficient to make a speedy cure, 
where the substantive inflammation of the nipple will admit of the 
cicatrization of the sore. 

I regard it as a matter of great consequence to touch only the 
granulations, and not the skin itself. To this end I take a fine 
camel-hair pencil and dipping it in a solution of the nitrate, I 
carefully pencil the granulations only; for I find it easy, with the 
delicate point of the pencil, to make the application exactly to the 
points I desire to touch. A solution of twenty grains to an ounce 
is strong enough. You will find, in many instances, that the 
extreme sensibility of the sore is lessened so much by the contact 
of the nitrate as to enable the woman to give suck to the child with 
much greater comfort. 

Mrs. De Groot, a monthly nurse here, a most sensible woman, 
in whose prudence and knowledge of her business I can confide, 
tells me that the nipple rarely becomes sore under her method of 
managing it. As soon as the child has left the nipple, Mrs. De 
Groot cleanses it with a bit of moistened linen. She dries it per- 
fectly, and then, taking the mamilla between the thumb and two 
fingers, she gently compresses it, with a view to assist it in dis- 
engorging its capillary vessels that are rendered turgid by the 
suction. As soon as she has rendered it soft and flexible again, 
she covers it thick with fine arrowroot powder, and keeps it in 
that way perfectly dry. I do not remember that the ladies she 
has nursed for me have, any of them, suffered from this annoying 
disorder. 
42 



658 THE BREAST. 

Dr. Physick taught me to cure a very bad nipple-sore in a 
patient he attended with me. He prepared a Very delicate adhe- 
sive strip by spreading adhesive plaster on a narrow ribbon called, 
by the shopkeepers, taste. 

"These gaping ulcers," said he, "are like gaping wounds. 
Their edges are separated too much; they will require a far 
greater quantity of granulations to heal them than if the edges 
should be approximated — bring them together then with the deli- 
cate strips of adhesive plaster, and keep them so — they will get 
w f ell much sooner." This advice was followed, and the effect 
w r as soon perceived in the amendment of the lady. 

Most of the French physicians use, for the treatment, an oint- 
ment made out of the juice of cucumbers — the pommdde de con- 
combres — and it certainly is one of the most emollient of the oint- 
ments. A good deal of it is employed here. In order to be 
useful, it should be freely applied. 

Borax, dissolved in mucilage of slippery elm, is a very plea- 
sant wash. It should be put into a salt-mouth phial, the throat 
of which is large enough to receive the nipple. Let the phial be 
turned up on the nipple as soon as the child leaves it. If held 
thus to the nipple a few moments, the whole surface is effectually 
moistened by the wash. 

Inflammation of the mammary gland, tending to abscess, is a 
warrant to order a venesection for a woman who is strong enough to 
bear the loss of blood, and there are few who are not strong enough, 
since those who are not, will, in general, not be found prone to 
these inflammations. You ought not then to hesitate to bleed for 
an inflammation of the gland, when the disorder threatens to be 
severe. 

Leeches freely applied, so they be not set upon an inflamed 
portion of skin, are very laudable. Many a hard nodule, threat- 
ening milk abscess, has been removed by twenty or thirty leeches; 
the operation to be repeated if the case demand it. 

A poultice is manifestly a useful remedy. But poultices ap- 
plied to the delicate skin of the mamma, are apt to bring out an 
eczema that adds to the discomfort. I think I have never had any 
such additional trouble, wdien I used a poultice made with bread 
and milk thickened with the petals of chamomile. It is a habit 
or routinism of my practice, and I venture to recommend it to a 
trial under your direction. 



THE BREAST, 659 

Where the nipple has been greatly inflamed and swollen, Ihave 
on many occasions directed a number of leeches, six to ten, to be 
applied just outside of the areola. For this end, I cut a disk of 
linen, or of diachylon-plaster to fit the areola, leaving a fenester 
for the nipple. The leeches cannot puncture the areola itself, if 
this precaution be taken — but their bites are all made beyond the 
circumference of the disk. You should not allow them to wound 
the aureole, because it renders the act of sucking more painful, 
and because the erythema that always attacks the leech-bite, 
would pass on to the nipple and aggravate, instead of diminish- 
ing, its inflammation. 

When the end of the nipple becomes abraded and inflamed, 
the inflammation runs along the milk tube deep into the substance 
of the mammary gland; and when it does so, a great difficulty is 
encountered in effecting a cure, short of the process of suppu- 
ration. When the end of the nipple, therefore, is abraded and 
ulcerated, you should give it a most careful attention, with a view 
to prevent so great a misfortune. 

When the breast must suppurate, it ought to be favored by the 
use of demulcent poultices. Powdered slippery-elm makes a 
good one — so does flaxseed-meal — but probably none is better 
than bread and milk with chamomile. 

When the suppuration has taken place, the matter ought to be 
discharged by means of a lancet, as soon as the abscess fairly 
points. When the cavity is become empty, by the discharge of 
the pus, let the breast be confined by means of strips of adhesive 
plaster, which constitute the most convenient suspensory and com- 
press for the organ. I am confident, the use of these adhesive 
strips has enabled me many times rapidly to cure a breast, which 
I should vainly have endeavored to cure in double the length of 
time by any other kind of dressing. 

The breast having suppurated, and the pus being discharged, 
whether by a spontaneous opening, or by means of the lancet, 
milk is sometimes seen to flow out together with the purulent mat- 
ter. Such a waste of the milk prevents the aperture from healing ; 
and the cavity of the abscess becomes a milk-fistula, which con- 
tinues for an indefinite period to discharge milk. When I find 
such a one, I push to near the bottom of the canal a very small 
bougie, made extempore of cere-cloth. Filling the orifice of the 
fistula, and probably irritating the internal granulations to a more 



660 THE BREAST. 

healthful activity, the bougie, generally, soon arrests the flow of 
milk from the orifice. The bougie becomes daily shorter at each 
successive repetition, and the fistula heals. 

If a woman have a suspicious nodule of long standing, in the 
breast, she ought not to nurse th£ child. The constant alterna- 
tions of fulness and flaccidity, and the augmented vital activity 
required to carry on the secretion of the nutriment, expose her 
to the danger of an inconvenient increase of the tumor, and to 
inflammation radiating from its superficies. Let her wean the 
child, by giving it to a wet-nurse. 

If you decide to remove the tumor or nodule by the bistoury, let 
it not be done until the milk has completely disappeared. The 
breast is not fit for the surgeon while it is a secreting gland. 

And now, having nothing further to propose as to the breast, I 
shall bring this letter, the last of the series, to a close. 

I wish, my dear friends, these letters were more worthy of your 
perusal; and I might, doubtless, have rendered them so, had I 
allowed myself, which I could not, more leisure from the daily 
business of my vocation, for their composition. 

Many of them have been written while waiting on women in 
labor ; and most of them at night, after the toils and anxiety of the 
day's practice : more than half of them, while suffering under a 
most distressing hemicrania. But I had made the promise to 
write and publish a series of letters to you, on the subject of 
Females, and their Diseases, in which I would speak, as nearly 
as possible, in the same tone and manner I should employ in 
speaking on the subjects, with any one or two of you in my library 
here, where I am now writing. 

I am aware that no man has a right to print a bad book; nor 
even apologize for faults in any book of his own making. I do 
not pretend to do so on the present occasion. I do, however, feel 
desirous that you should not forget the occasion that so suddenly 
prompted me to engage in this task ; nor overlook the fact that I 
did not begin these letters of 660 pages until about the middle of 
last May. 

I have found the mechanical labor of it severe. 

" Sed tua me virtus tamen, et sperata voluptas 
Suavis amicitias, quemvis efferre laborem 
Suadet ; et inducit noctes vigilare serenas 
Querentem dictis quibus, et quo carmine demum 
Clara tuae possim prsepandere lumina menti 
Res quibus occultas penitus convisere possis." 



THE BREAST. 661 

These beautiful lines of the poet Lucretius, I quote from the 
Treatise de Rerum JYatura, and I do so in order that the dead 
Roman might speak, arid say, in better language than any I could 
indite, how strong the motive that has induced me to this labor. 
Pray, then, receive this workofiiis head, his heart, and his hands, 
from your former Instructor, with kindness, and assist him to 
invoke for it the favorable consideration of all our brethren of 
the Medical Profession, who I hope will see in it the evidences of 
a sincere desire to promote the dignity and usefulness of our 
vocation. 

I pray you ever to look upon the medical profession, not as a 
business, but as a great Morality — not as a trade, but as a Mission 
appointed by God, for the benefit of the children of men. 
Farewell, dear gentlemen, and believe 
me, affectionately, your friend 
and respectful servant, 

CHARLES D. MEIGS. 
Philadelphia, 26th Nov. 1847. 



INDEX 



Abdominal neuralgia, 131 
Aberdeen fever by Gordon, 590 
Abortion, 

causes of, 150, 522, 538 

diagnosis of, 525 

habitual causes of, 540 

tampon in, 528 

treatment of, 530 
Abscess of labium, 78 

of mamma, 659 
Absorption from pressure of pessaries, 176 
Abyssinia, customs in, 82 
Acetate of lead in menorrhagia, 433 
Acid nitrate of mercury, 264 
Acute ovaritis, 302 
Alum in menorrhagia, 433 
Amenorrhoea, 405 

blood-letting in, 422 

caution in diagnosis of, 406 

debility as cause of, 421 

rheumatism as cause of, 418 
Amussat, M., 1 93 
Anaemia, 145 

Anaemia from polypus, 257 
Anaemia, puerperal, 502 
Anaemia, treatment of, 1 60 
Analogy of labor and hysteria, 458 
Anatomie Transcendente of Serres, 267 
Anatomy of ovary, 386 
Ann Ryder's case, 250 
Ante vers ion of womb, 219 
Antispasmodics, 469 
Aphrodisiac power, the, 462 
Asdrubali's objections to binder, 568 
Atresia vaginae, 91 
Aura hysterica, 457 
Aureole of the breast, 650 
Auscultation, obstetrical, 489 
Avenzoar's method in prolapsus, 141 

B 

Bad training, 165 
Baer, Lager of, 30 

on the stroma, 30, 394 
Bulgrudery, Dennis, 23 
Bandage after labor, 568 



Barclay's, Col., training method, 155 
Bee, larva of, non-sexual, 34 
Bennet on ovarian dropsy, 307 

on prolapsus, 137 
Betton's, Dr., case of inversion, 241 
Bichat's vital triad, 345 
Bischoff on corpus luteum, 397 
Bladder, inverted, 125 
Bleeding in oedema gravidarum, 498 

in amenorrhcea, 422 
Blood, 

anaemical, analyses of, 155 

formation of, 340 

healthy, analyses of, 153, 154, 410 

menstrual, analyses of, 411 

quantity of in body, 152 

thin, 150 
Blood-membrane, 152, 168 
Blumenbach on the clitoris, 118 
Blundell's pessary, 72, 181 
Boivin's pince a faux-germe, 536 
Boivin and Duges on physometra, 2S9 

on ovaritis, 302 
Boschismans, 87 
Bougies, 89 
Brainerd's case, 74 
Breast, the female, 643 

dialogue on the, 643 

drawing the, 652 

inflammation of the, 659 

weed in the, 645 
Brierre de Boismont, 378, 402 
Brown's formula for tympanitis, 295 
Browne, Sir Thomas, his Religio Medici. 

29 
Burdach, 342 



Cancer, 

cause of, 279 
Muller on. "281 
of the womb, 27 S 

treatment of, 2 S3 

Candor necessary, 20 

Caoutchouc pessaries, 17$ 

Carcinoma uteri, 27$ 

Carminative, Dr. Brown's, 295 



664 



. INDEX. 



Carus' curve, 129, 317 
Case, 

of abdominal neuralgia, 131 

of abortion, 524, 536, 537, 544 

of absence of vagina, 85 

of anaemia from polypus, 257 

of chlorosis, 389 

of chronic retroversion, 206 

of cohesion of vaginal walls, 97 

difficult, of retroversion, 203 

of disease of clitoris, 122 

of double vagina, 110 

Dr. Ingleby'Sj of retroversion, 204 

of dysmenorrhcea, 439 

of enlarged clitoris, 120 

of excision of do., 122 
of nympha?, 117 

of fatal distension of Fallopian 
tubes, 325 

of fibrous tumor, 274 

of habitual abortion, 540 

of hysteria, 465, 469 
in male, 459, 460 

of immobility of womb, 585 

of imperforate hymen, 94 

of inversion, 232, 234 

of inverted bladder, 525 

of large polypus, 285 

of long retained pessary, 175 

Mayor's, of retroversion, 203 

of menorrhagia, 429 

Miss Helen Blanque's, 145 

of nymphomania, 123 

of ovarian pregnancy, Granville's, 
329 

of ovaritis, 302 

of protracted disease from false deli- 
cacy, 20 

of puerperal anaemia, 503 

of puerperal convulsion, 633, 640 

of relaxed symphyses, 513, 517 

of retroversion, 198 

of salivation, 480 

of simulative pregnancies, 291, 292, 
293 

of tubal pregnancy, 279 

of tympanitis uteri, 294 

of ulceration of vagina, 98 

of vaginal enterocele, 107 

of vaginal fistula, 104 

of vomiting, 483 
Catheterism, 571 
Causes of early fading, 355 
Cazeaux, 193 
Celery blanched, 159 
Cell-life, 27 
Cereoles, 89 
Cerise, Dr., 168 
Cervix uteri, structure of, 437 

application of leeches to, 422 

excision of, 282 



Cesarian operation, motives for, 313 
Champagne in vomiting, 484 
Change of life, 444 
Changes of puberty, 337 

cause of, 444 

dangers of, 446 

management of, 448 

time of, 453 
Chapman on emmenagogues, 416 
Child-bed fever, 576 
Children, male and female, compared, 35 
Chlorosis, 344 

case of, 344, 359 

causes of, 346 

treatment of, 438 
Chronic retroversion, 206 
Churchill on round ligaments, 193 
Cicatrix of perineum, 79 
Circumcision in Abyssinia, 82 
Cleanliness in cancer, 284 
Climate of the United States, 355 
Clitoris, the, 118 

Blumenbach on, 118 

enlarged, 120 
Coherent labia?, 113 

nymphee, 113 
Cohesion of vaginal walls, 96 
Colles, 59 
Collins, Dr., 485 
Colombat on inversion, 134 
Common sense in practice, 26 
Conduct, remarks on, 18 
Congenital narrowness of vagina, S8 
Constipation, 497 
Contagion of puerperal fever, 580 
Contracted vagina, dilatation of, 89 
Convulsions in puerperal women, Letter 

on, 631 
Cork pessaries, 178 
Corpus luteum, the, 32, 393 
Counter-sunk nipple, 651 
Crises of life, 335 
Crosse's case of inverted bladder, 125 

on inversion of the womb, 227 
Crural phlebitis, 624 
Cullen on emmenagogues, 417 
Cure, spontaneous, of inversion, 237 
Cysts in labium, 72 



Daillez cases, 240 

Debility as cause of amenorrhaea, 421 

Definition of puberty, 333 

Delicacy of the relations of physician 

and patient, 19 
Deleurye on the round ligaments, 193 
Depaul on obstetrical auscultation, 498 
Desormeaux and Paul Dubois on round 

ligaments, 193 
Development of womb, cause of, 474 
Dewees, Dr., an opinion of his, 643 



INDEX. 



665 



Dewees on inversion, 235 

on pessary, 171 

on placenta hook, 536 

on retroversion, 205 

volatile tincture of guaiac, 443 
Diagnosis, hasty, 251 
Dialogue on the breast and its disorders, 
643 

with a patient, 145, 199, 230, 254, 
261, 354 
Diet, for accouchee, 481 

in anaemia, 161 
Difficulties in diagnosis, 135 
Digitalis, 509 

Dilatation of contracted vagina, 90 
Diseases of ovaries, 299 
Disorders of pregnancy, 472 
Displacements of womb, 127 
Distension of bladder, danger of, 193 
Distinctive characteristics of the female, 

37 
Doctor Henry Bond's placenta forceps, 
536 

Clarke's London practice, 21 

Fendal's case, 544 
Double vagina, 110 
Dropsy of womb, 290 

of ovary, 304 

of ovary, diagnosis of, 305 
Dublin Lying-in Hospital, 585 
Duges, M., 586 
Duration of pregnancy, 499 
Dysmenorrhosa, 434 

causes of, 436 

pseudo-membranous, 442 

symptoms of, 435 

treatment of, 440 



Early marriages, 376 
Eclampsia, 631 
Education of women, 369 
Egan's account of Tom Crib, 155 
Egg unfecundated, 30 
Emansio mensium, 338 
Embryo, non-sexual, 34 
Emmenagogues, 416 

Chapman's list of, 416 

Cullen on, 417 
Encysted dropsy, cases of, 305, 306, 310 
Endangium, 341 

Burdach on, 342 

in disease, 343 

nature of, 341 

Raciborski on, 343 
Engorgement of uterus, treatment of, 450 
Enlarged clitoris, 120, 122 

nymphse, 116 
Ephelis, 480 
Epidemic influence, 582 



Epidemic puerperal fever, 580 

Ergot in polypus, 250 

in menorrhagia, 429, 433 
used to produce abortion, 522 

Erysipelas connected with puerperal 
fever, 589 

Etiolation, 159 

Everted urethral membrane, 126 

Excision of nymphae, 117 
of cervix uteri, 282 

Exercise, importance of, 158, 357 

Explanation of puerperal fever, 601 

Exploration of a case of ansemia, 147 

Exploration of flexio uteri, 224 

External organs, 54 



Fabricius, case by, 80 
Fallopian tubes, 384 

fatal distension of, 352 

inflammation of, 325 
False delicacy, case showing the effects 

of, 20 
False membrane in dysmenorrhoga, 442 
Fasciola of adhesive plaster, 651 
Felix Plater, 59 

Female, distinctive characteristics of, 37 
Fever, child-bed, 577 

milk, 645, 653 
Fibrous tumors, 264 

cause of, 274 

mechanical relief of, 275 

nature of, 264, 271 

treatment of, 276 
Figure, 193 
Fistula, vaginal, 104 
Flexion of the womb, 223, 225 
Flourens, M., referred to, 636, 641 
Forbes, Dr., 27, 166 
Formation of blood, 340 
Free-Martin, 121 
Function of ovaries, 300 



Galactophorous tubes, 648 

Gendrin on menstruation, 391 

Generic laws, 3S1 

Georget on hysteria, 465 

Germiferous and fecundating attributes, 

31 
Germinal spot, 31 
Germs, periodicity of the production of, 

383 
Globe pessary, 172 
Gooch's canula, 255 
Gordon on contagiousness, 587 

on puerperal fever, 590 
Graafian follicles, 300 

cell, 32, 300 
Granville's case of ovarian pregnancy, 329 



666 



INDEX. 



Grauiex, Dr.. of Brussels, 58 
Guaiac, volatile tincture of, 443 

H 

Hsematosic tissue, 340 

Hale, Horatio, 81 

Hasty diagnosis. 261 

Heart, nerves of the, 604 

Heberden, 141 

Helen Blanque's case, 145 

Henle on corpus luteum, 395 

Hermaphrodism, 119, 121 

Hervez de Chegoin, 172 

Hey, Mr. William, 607 

Hippocrates on prolapsus uteri, 141, 143 

Holland, Dr. Henry, 640 

Honey-bee, 35 

Hooper, Dr., 573 

Hordeolum, 480 

Horse-shoe pessary, 181 

Hunter, John, on free-martin, 121 

"William, on retroversion, 199 
Huschke, views, 387 
Hydatids. 297 

Hydrometra, treament of, 299 
Hypertrophy, a physical sin, 244 
Hysteria, 455 

analogy with labor, 45 S 

cases of, 465, 469 

causes of, 456, 464 

diagnosis of, 467 

influence of womb on, 455 

in the male, 459 

symptoms of, 467 

treatment of. 46 S 

I 
Ignorance of the public as to medicine, 

19,23 
111 success from fastidiousness, 18, 21 
Immobility of the womb, 185 
Imperforate hymen, 91 
Influence of climate, &c, on menstrua- 
tion, 375 

of pessary on excretion, 187 

of pessary on conception, 187 

of retroversion on general health, 
195 

of womb in hysteria, 455 
Ingleby's case of retroversion, 204 
Internal organs, 54 
Inversion of womb. 227 

case of, 232, 239 

Colombat on, 234 

Dewees on, 235 

diagnosis of, 229 

of mucous membrane of the vasina, 
103 

spontaneous cure of, 236 

treatment of, 232 
Inverted bladder. 125 



Itching of vulva, 77 

Jacquemier on the round ligaments, 193 



Kennedy on obstetrical auscultation, 492 
Krauss, 59 



Labia pudendorum, 59 

coherent, 113 

injuries of, 60 

laceration of, 69 

cedema of, 60 

puncture of, 61 

structure of, 59 

thrombus of, 65 

treatment of, 66 
Labial abscess, 78 
Labial warts, 73 
Labium or labrum, 59 

cysts of, 72 

ruptured, 68 

thrombus of, case, 65 
treatment, 66 
Laceration of perineum, 71 

results of, 72 
Lady "Webster's pill, 368 
Larva of bee, non-sexual, 34 
Lawrence on the nymph ae, 81 
Lay cock on morbi simulati, 465 
Lee, Dr. Robert, on crural phlebitis. 625 

on puerperal fever, 586 

on puerperal fever and crural phle- 
bitis, 592 

Dr. Thorn. S., on polypus, 247 

his tables, 306 

on tapping, 307 
Levators in prolapsus, 133 
Levret on prolapsus, 134 
Ligamenta rotunda in retroversion, 191 

relaxed after labor, 209 
Lisfranc on excision of cervix, 283 
London practice, by Dr. Clarke, 27 
Longet, M., 604 
Longings, 488 
Louyer Villerrnay's case, 120 

M 

Mackintosh's cases, 438 
Macula germinativa, 31 
Maiors case of retroversion, 203 
Malgaigne on vaginal rectocele, 106 
Malignant degeneration of polypus, 254 
Mammary abscess, 659 

glands, 643 
Marshall Hall on hysteria, 458 
Mauriceau's case of excision of nymphae, 

107 
M. Baudelocque, Jr., 5S6 
Mechanical disorders of pregnancy, 475 
Medical notes by Dr. Holland, 640 



INDEX. 



667 



Medicine for the accouchee, 507 
Medicines, power of, 168 
Membrana vasorum commune, 342 
Menorrhagia, 424 

case of, 428, 430 

ergot in, 429, 433 

styptics in, 433 

tampon in, 429 

treatment of, 430 
Menstrua, ancient notions of, 413 

the, 374 
Menstruation, first, 375 

causes of, 376 

condition of ovary in, 389 

during pregnancy, 404 

premature, 376 

return after labor, 402 
Mensual discharge, rate of, 407 

nature, 408 

quantity, 408 
Mental qualifications of physicians, 20 
Merriman on retroversion, 194 

on excision of clitoris, 122 

tables, 520 
Mery, Antoine de St., case, 90 
Metro-peritonitis, 577 
Migratory animals, 383 
Milk, secretion of, after miscarriage, 527 
Milk-fever, 645, 653 
Milk-leg, 625 
Milk-tubes, 648 
Miquelard ; s iron, 161 
Miscarriage, secretion of milk after, 527 
Miss Helen Blanque, 145 
Mons veneris, 55 

diseases of the, 55 
Monticuli, 59 
Moreau,Prof, 51 

case, 513 
Motives to write, 17 
Muller on cancer, 281 
Mystery and jargon in physic, 25 

N 
Narrowness, congenital, of vagina, 88 
Nascent polypus, 263 
Nature of the menstrual fluid, 408 

of endangium, 341 

of vitellus of ovary, 394 
Nausea and vomiting, 482 
Neuralgia abdominal, 131 
Neurosity, 169, 383 
Neygrier on menstruation, 391 
Ninth day, 574 
Nipple, 648, 650 
Nipple-shield, 651 
Nipple-sore, 656 
Nondina?, 574 
Nymph a?, 79 

coherent, 113 

elongated, 116 



Nymphae, 

lost, cause of, 80 

none in mammals, 81 

torn, 82 

ulcerated, 116 
Nymphomania, 123 

case, 123 

treatment, 124 



Obstetrical auscultation, 489 
(Edema gravidarum, 60, 496 

case, 62 

labiorum, 60 
Ovarian cysts, 303 

Bennet on, 307 

causes of, 301 

disease, 300 

dropsy, 304 

pregnancy, 329 

spontaneous cure of, 306 

stroma, 386 
Ovaries, diseases of, 299 

function of, 304 
Ovariotomy, 311 

Simpson on, 313 

statistics of, 316 
Ovaritis, 302 

case of, 302 

treatment of, 303 
Ovary, anatomy of, 386 

state of during menstruation, 389 
Ovulation, process of, 399 

in mammifers, 391 

periodicity of, 385 
Ovulum, 30 
Ovum, 32 

retained, 524 



Pain of miscarriage, 524 
Pales couleurs, 544 
Palpitations, 501 

causes of, 502 

in chlorosis, 346 

diagnosis, 503 

treatment, 507 
Pancoast's operation in spasm of vagina, 
185 

for vaginal fistula, 104 
Parent du Chatelet, 120 
Pelvic articulations, strain of, 510 
Pennsylvania Hospital, 589 
Perineum, lacerated, 71 
Periodicity of menstruation, 377 

of germ production, 383 

of ovulation, 385 
Peritoneal fever, 576 
Peritonitis, 577 
Pessary, Dewees, 171 

absorption from, 176 



668 



INDEX. 



Pessary, 

Blunders, 72, 181 

caoutchouc, 178 

cork, 178 

elastic, 172 

en bilboquet, 180 

globe, 172 

horse shoe, 181 

long retained, 175 

Physick's, 171 

relief derived from, 170 

sponge, 178 

Stern, 180 

use of the, 174 

ulceration from, 176 

whalebone, 178 
Pessaries, 141 

ancient, 141 

precautions as to, 187 

rules for the employment of, 188 

Warner's, 171 
Pet- vaginal, 289 
Phlebitis crural, 577 

of the leg, 630 
Phlegmasia alba dolens, 625 
Phrenology examined, by Flourens, 641 
Physical sin, 244 
Physician and patient, 19 

mental qualifications of, 20 

personal appearance of, 28 
Physick, Dr., his method in phlebitis, 630 
Physick's pessary, 172 
Physometry, 288 

cause, 289 
Pills of Quevenne's metallic iron, 161 

Lady Webster's, 368 
Placenta, 521 

forceps, Dr. Henry Bond's, 526 

hook, Dewees', 526 
Polypus uteri, 241 

anaemia from, 257 

cases, 250, 251 

causes, 242 

diagnosis, 249 

ergot in, 258 

large, case of, 245 ' 

Lee on, 247 

malignant degeneration of, 254 

mode of removing, 256 

nascent, 263 
Pouchet's views, 390 
Pouting of the navel, 472 
Pregnancy in retroversion, 208 

cause of retroversion, 209 

disorders of, 472 

menstruation during, 404 

ovarian, 329 

signs of, 480 

tubal, 326 
Premature menstruation, 326 
Process of growth, 340 



Process of ovulation, 394 
Procidentia uteri from lacerated peri- 
neum, 72 
Prolapsus uteri, 178 

causes of, 139 

diagnosis of, 164 

general treatment of, 174 

hygienical means in. 174 

in the unmarried, 183 

simulative, 144 

vagina in, 135 

with neuralgia, 132 
Pruritus vulvae, 77 
Puberty, 331 

exercise in, 357 

meaning of the term, 333 

signs of, 337 
Pubic symphyses relaxed, 37, 511 
Pudenda, 54 
Puerperal anaemia, 502 

cases of, 633, 640 

convulsions, 631 

described, 633 

diagnosis, 604 

Dublin, 584 

fever, 576 

Gordon on, 607 

symptoms, 604 

treatise of, 641, 643 

treatment, 604 
Purification of accouchee, 575 
Purkinje, 394 
Pyogenic fever, 577 



Q 



Quackery, 23 
Quevenne's iron, 161 

marked effects of, 285 
Quickening, 479 



Raciborski on endangium, 343 

on menstruation, 391 

on veins, 600 
Rapid growth at puberty, 339 
Recumbency in habitual abortion, 542 
Relaxed symphyses, 56, 513 

Grauiex, seton in, 58, 513 

pelvis, 56,513 
Relief derived from pessaries, 170 
Religio Medici, 129 
Remarks on conduct, 18 
Retained ovum, 525, 534 

placenta, 526 
Retroversio uteri, 190 

Blundell's instrument, 217 

causes, 191, 209 

chronic, case of, 206 

influence of, on health, 195 

in pregnancy, 214 



INDEX. 



669 



Retroversio uteri, 

Mayor's case of, 212 

pregnancy during, 208 

reposited, 215 

round ligaments in, 218 

signs, 216, 217 

symptoms, 199 

treated, 201, 205 

Wier's case, 210 
Return of menstruation after labor, 402 
Rheumatism of womb, 408 

cause of dysmenorrhasa, 436 
Riding out, 575 

Robert Lee on menstruation, 391 
Round ligaments, Velpeau on, 193 

Deleurye on, 193 
Routineers, 32 
Rudolph Wagner, 31, 394 
Rule for employment of pessaries, 188 
Rupture of labium, 69 

to avoid, 70 

of perineum, 71 
Rutter, Dr., 583 

his success, 584 



Sachets, 177 

Sea bath, 367 

Seneca cited, 156 

Serous inflammation of the abdomen, 578 

Serres, M., extract from, 267 

Seton, Grauiex, 58, 518 

Sex, 30, 34, 38 

derivation of 34 

proportion of, 34 

undistinguishable in early embryo, 
34 
Sieur de la Motte, 128 
Simpson on ovaries, 313 
Simulated diseases of hysteria, 465 

pregnancy, 291 
Simulative prolapsus, 144 
Sin, physical, 244 
Sitting up in the month, 574 
Small-pox, contagion of, 511 
Sore-nipple, 656 
Spach's Gynoeciorum, 142 
Sponge pessaries, 178 
Spontaneous cure of inversion, 236 

cases, 237 
Statistics, 23 

of menstruation, Brierre de Bois- 
mont's, 402 

of ovariotomy, 316 
Stem pessary, 180 
Strain of pelvic articulations, 510 
Strangury, 510 
Stricture of cervix uteri, 437 

of vagina, 89 
Strophium of adhesive plaster, 651 
Suckling, 654 



Suffita, 177 

Suppression of catamenia, 351 

Sydenham's case of hysteria in the male, 

460 
Sydenham on hysteria, 461 
Symphyses relaxed, 56, 513. 



Tablier des Hottentotes, 81 
Tampon, in abortion, 528 

in monorrhagia, 429 
Tenesmus uteri, 134 
Thrombus labii, 66 
Tinct. black hellebore, in dysmenorrhcea, 

442 
Tissue hsematosic, 340 
Tom Crib's training, 153 
Tonic spasm of sphincter vagina?, 1 84 
Tonnele, 593 

tables by, 597, 599 
Training, bad, 165 
Triad, vital, of Bichat, 348 
Tubal pregnancy, 326 

case, 327 
Tumors, fibrous, 264 
Tympanitis, 293 

cure of, 294 

of puerperal fever, 602 

treatment, 295 

uterine, 288 

U 
Ulcerated nymphas, 116 

vagina, 98 
Ulceration from pessary, 179 
Urethral membrane inverted, 126 
Urine, retention of, 570 
Use of pessary, 174 
Uterine polypus, 241 
Utero-abdominal supporter, 24, 188 
Uterus, prolapsus of, 128 

puncture of, 87 



Vaccination of pregnant women, 575 
Vagina, absence of, 85 

cohesion of walls, 91 

congenital narrowness of, SS 

double, 110 

inversion of mucous membrane of, 
103 

in prolapsus uteri, 134 

relations of, S5 

stricture of, S9 

ulceration of, 98 
Vaginal cystocele, 109 

enterocele, 107 
case, 107 

fistula, 104 

Pancoast's operation for, 104 

rectocele, 106 



670 



INDEX. 



Vaginal wall, cohesions of, 91 
Vaginitis, 100 

Value of hymen as a sign, 184 
Vapors, 457 
Varix gravidas, 499 
Veins, Raciborski on, 600 
Velpeau on round ligaments, 191 
Venesection in retroversion, 205 
Ventose pregnancies, 288 
Verruca? of labia, 73 
Virginity, hymen as proof of, 185 
Vital triad of Bichat, 398 
Vulva, warts of, 73 
pruritus of, 77 

W 

Walking exercise, 147 
Walking pestilence, 585 
Warts of labium, 73 
Whalebone ring pessary, 179 
White's, Dr., case of inversion, 234 
Wier's, Dr., case of retroversion, 210 



Wigand, Justus Heinrich, 225 
Willis de Febribus, 586 
Woman, education of, 369 
Womb, 127 

ante version of, 219 

cancer of, 278 

treatment of, 283 

cause of development of, 474 

displacements of, 127 

dropsy of, 296 

engorgement of, 450 

flexion of, 213 

inversion of, 225 

prolapsus of, 128 

retroversion of, 190 

rheumatism of, 418 

tympanitis of, 288 



Yelk ball, 30 

how constituted, 31 
Young Physic, 27, 166 



THE END, 



3477 

1269 



ERKATA. 

For " Quenesville" read " Quevenne" passim. 

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